Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Spinal Stenosis.
Treatment:  Increase PCA (personal care aide) 12 Hours Per Day, 7 Days A Week.

The insurer denied: Increase PCA (personal care aide) 12 Hours Per Day, 7 Days A Week.  The denial is overturned.

This patient is an elderly female diagnosed with spinal stenosis, atrial fibrillation, and depression. She is appealing the denial of increase for a PCA (Personal Care Aide) for 12 hours per day, seven days a week. The health plan approved eight hours per day, seven days a week. A performed Uniform Assessment System evaluation completed recently shows modified independent cognition and functional status: total dependence with meal preparation, and housework; maximal assistance with bathing; extensive assistance with dressing, walking, locomotion, and toileting; limited assistance with managing finances and medications, phone use, personal hygiene, and bed mobility; and independent with eating. She has bowel and bladder incontinence. Compared to a Uniform Assessment System evaluation completed nine months earlier there was a decline with managing medications, phone use, bathing, walking, locomotion, and bed mobility. An appeal letter from the patient notes that she reports being unsteady and has fallen. She needs nighttime assistance with toileting every two hours and cannot safely transfer. She has nighttime confusion and needs to be watched 24/7. A letter from the provider states the patient has weakness and an unsteady gait. The patient reportedly needs help with ADLs (activities of daily living) and a walker alone is insufficient. She needs nighttime assistance with toileting every two hours and cannot safely transfer. She has nighttime confusion and needs to be watched 24/7. The provider recommends homecare 84 hours per week. 

The proposed treatment of an increase for a Personal Care Aide 12 hours per day, seven days a week is considered 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. This patient is appealing the denial of an increase of Personal Care Aide to 12 hours per day, seven days a week. The health plan approved eight hours per day, seven days a week. 

A Uniform Assessment System evaluation completed recently shows the patient needs assistance with all ADLs (activities of daily living), except eating and reportedly has bowel and bladder incontinence. Compared to a Uniform Assessment evaluation completed nine months earlier there was a decline with managing medications, phone use, bathing, walking, locomotion, and bed mobility. An appeal letter notes that the patient is unsteady, needs nighttime assistance and to be watched 24/7. 

The information provided shows that this member has significant limitations in functioning. The UAS (Uniform Assessment System) evaluations and appeal statements support the need for additional PCA (Personal Care Aide) hours. The approved PCA (Personal Care Aide) 8 hours per week is insufficient to meet this member's needs for assistance with ADLs (activities of daily living). The proposed increase PCA (Personal Care Aide) to 12 hours per day, 7 days per week is medically necessary.