Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, heart failure, and dementia
Treatment: Increase Personal Care Aide Services to Live-in Per Diem for a Total Amount of 7 Days per Week
The insurer denied: Increase Personal Care Aide Services to Live-in Per Diem for a Total Amount of 7 Days per Week
The denial is overturned

This elderly female has conditions including osteoarthritis, heart failure, and dementia. She was admitted with a urinary tract infection and hyponatremia. She is appealing denial of an increase in personal care aide services to live-in per diem for a total amount of seven days per week. The health plan approved 52.5 hours per week. Uniform Assessment System (UAS) evaluation performed recently shows the patient has moderately impaired cognition and functional status: total dependence with meal preparation, housework, and managing finances; maximal assistance with managing medications and finances, bathing, personal hygiene, dressing, walking, locomotion, and toileting; extensive assistance with bed mobility; and limited assistance with eating. Uniform Assessment System (UAS) evaluation completed 2 months previously shows a decline in all levels of functioning, except lower body dressing and bathing. The patient has bowel and bladder incontinence. A statement on a prescription note states the patient is not safe at home alone and needs 24/7 home care.

The proposed treatment is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, walking, transfers, turning/positioning, or feeding.

This patient has multiple chronic conditions, including recent hospital admission for urinary tract infection. She is appealing the denial of an increase in personal care aide services to live-in per diem for a total amount of seven days per week. The health plan approved 52.5 hours per week.

The plan denied the request based on the two recent Uniform Assessment System assessments completed recently and 2 months previously which showed some of the patient's abilities to perform daily activities stayed the same and some declined such as dressing upper body, personal hygiene, bed mobility, walking, locomotion, toilet transfer, toilet use, eating and medication management. Uniform Assessment System (UAS) evaluation completed recently shows the patient requires extensive assistance to total dependence with all activities of daily living, except limited assistance with eating. Uniform Assessment System evaluation completed 2 months previously shows a decline in all levels of functioning, except lower body dressing and bathing. The patient has bowel and bladder incontinence. The information provided shows that this patient has significant limitations in functioning. The approved personal care aide services at 52.5 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to live-in per diem for a total amount of seven days per week is medically necessary.