Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Heart failure, arthritis, hypertension, and dementia.
Treatment:  Increase Personal Aide (PCA) Services To 12 
Hours Per Day 6 Days A Week/ and 4 Hours Per Day, 1 Day a Week (Saturdays).

The insurer denied: Increase Personal Aide (PCA) Services To 12 Hours Per Day 6 Days A Week/ and 4 Hours Per Day, 1 Day a Week (Saturdays).  The denial is overturned.

The patient is an elderly female. She has multiple medical conditions, including heart failure, arthritis, hypertension, and dementia. Denial of increase personal aide (PCA) services to 12 hours per day 6 days a week and 4 hours per day, 1 day per week (Saturdays) is being appealed. The health plan approved 10 hours per day, 6 days per week and 4 hours per day, 1 day per week (Saturdays).

The patient's Uniform Assessment System (UAS) evaluation completed recently shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing finances, phone use, and bathing; extensive assistance with managing medication, personal hygiene, dressing, and toileting; limited assistance with walking and locomotion; and supervision with bed mobility and eating. The patient has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation from earlier this year, there has been a decline with meal preparation, shopping, bathing, personal hygiene, dressing, and toileting. The appeal notes that the patient has prominent memory problems. Her memory is declining. That affect daily activities. She forgets to take medication and eat her dinner. She needs significant assistance with ADLs (activities of daily living) and IADLs (instrumental activities of daily living).

The requested Increase Personal Aide (PCA) Services To 12 Hours Per Day 6 Days A Week/ and 4 Hours Per Day, 1 Days a Week (Saturdays) is medically necessary.

Personal Assistance 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 aide (PCA) services to 12 hours per day 6 days a week and 4 hours per day, 1 day per week (Saturdays) is being appealed. The health plan approved 10 hours per day, 6 days per week and 4 hours per day, 1 day per week (Saturdays).

The patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation recently completed shows the patient requires assistance with all ADLs (activities of daily living), except bed mobility and eating. Compared to UAS (uniform assessment system) evaluation completed earlier this year, there has been a decline with meal preparation, shopping, bathing, personal hygiene, dressing, and toileting. Appeal statements from providers note there has been a decline in memory and physical functioning. This patient's physical functioning is significantly impaired and has progressed between UAS (uniform assessment system) evaluations. The need for assistance with all ADLs (activities of daily living) cannot be met with the approved PCA (personal care assistant) hours. The requested increase PCA (personal care assistant) services to 12 hours per day 6 days a week and 4 hours per day, 1 day per week (Saturdays) is medically necessary.