Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment, diabetes. 
Treatment: Personal Care Assistance Services for a Total of 84 Hours per week. 

The insurer denied: Personal Care Assistance Services for a Total of 84 Hours per Week. 
The denial is Overturned. 

This elderly female patient has conditions that include Parkinson's disease, cognitive impairment, osteopenia, hypertension, hyperlipidemia, hypothyroidism, and diabetes. The denial of personal care assistance services, for a total of 84 hours per week, is being appealed. The plan approved 35 hours per week. Uniform Assessment System (UAS) evaluation completed three months ago shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, managing finances and medications, and shopping; extensive assistance with phone use, stairs, transportation, bathing, lower body dressing, bed mobility; and toilet use; limited assistance with upper body dressing, walking, and locomotion; supervision with personal hygiene; and independent with eating. She has bladder and bowel incontinence. Compared to Uniform Assessment System evaluation completed seven months ago, there has been no significant change in physical functioning. 

An appeal statement from New York State notes the patient has had several falls. She has decline in physical and cognitive functioning. The increase in hours is indicated for assistance with medications, dressing, walking and transferring, bed mobility, toilet, and meal preparation and eating. Due to incontinence, she requires several clothing changes throughout the day. She requires assistance with ambulation throughout the day. 

The proposed treatment 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. This patient has multiple chronic conditions. The denial of personal care assistance services, for a total of 84 hours per week, is being appealed. The plan approved 35 hours per week. The health plan denied the increase in hours based on the Uniform Assessment System evaluation. The plan notes that personal care assistance is not indicated for safety supervision and personal care tasks can be accomplished with the approved time. Uniform Assessment System (UAS) evaluation completed three months ago shows the patient needs assistance with all activities of daily living, except personal hygiene and eating. She has bladder and bowel incontinence. Compared to Uniform Assessment System evaluation completed seven months ago, there has been no significant change in physical functioning. However, appeal statements note the patient's physical and cognitive functioning have deteriorated. The patient needs assistance with activities of daily living, including assistance with toileting and ambulation throughout the day. She has a history of falls. The information provided shows that this patient has significant limitations in functioning. She has frequent urinary unscheduled incontinence. The approved personal care assistance 35 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 84 hours per week is medically necessary.