Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease dementia, lower extremity edema, glaucoma, and Foley catheter
Treatment: Increase Home Care/ Personal Care Level 2 Per 15 Minutes To 84 Hours Per Week
The insurer denied the Increase Home Care/ Personal Care Level 2 Per 15 Minutes To 84 Hours Per Week
The denial is overturned

The patient is a male. He has multiple conditions, including Parkinson's disease dementia, lower extremity edema, glaucoma, and Foley catheter. He lives alone. Denial of increase home care/ personal care (PCA) to 84 hours per week is being appealed. The health plan approved increase to 63 hours per week.

Uniform Assessment System (UAS) evaluation performed showed modified independent cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with bathing, lower body dressing, locomotion, and toilet use; extensive assistance with managing finances and medications, personal hygiene, upper body dressing, waking, and toilet transfer; limited assistance with bed mobility; and supervision with eating. The patient is noted to need assistance and supervision at all times. He has infrequent bowel incontinence. No hospitalizations or ER (emergency room) visits were noted in the prior 90 days. Compared to UAS (Uniform Assessment System) evaluation completed previously, there is a decline in functional status with the following: meal preparation, housework, managing finances, shopping, bathing, lower body dressing walking, locomotion, toileting, bed mobility, and eating.

Yes, the requested Increase Home Care/ Personal Care Level 2 Per 15 Minutes To 84 Hours Per Week is medically necessary.

Appeal statements note that the patient has several chronic conditions. He does not have informal support. He has experienced 3 falls in the prior 90 days. His condition has progressed. He has difficulties with ambulation and requires assistance throughout the day.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase personal care services to 84 hours per week is being appealed. The health plan approved increase to 63 hours per week.

The patient has several chronic conditions including Parkinson's disease and dementia. Uniform Assessment System (UAS) evaluation performed showed the patient requires assistance with all ADLs (activities of daily living). Compared to UAS (Uniform Assessment System) evaluation completed previously, there is a decline in functional status with: meal preparation, housework, managing finances, shopping, bathing, lower body dressing walking, locomotion, toileting, bed mobility, and eating. The appeal letters note there has been a decline in the patient's condition, which is supported by the UAS (Uniform Assessment System) evaluations, and requires assistance throughout the day. This patient has physical impairments that have significant progressed between UAS (Uniform Assessment System) evaluations. The amount of assistance needed cannot be met with the approved PCS (personal care services) at 63 hours per week. The proposed increase in PCS (personal care services) to a total 84 per week is medically necessary.