Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive cerebellar degeneration.
Treatment: Increase Personal Care Aide (PCA) Level II Services to 12 hours per day - 7 days per week, 12 hours per day - 7 days per week - for a total of 168 hours per week (split shift).
The insurer denied the Increase Personal Care Aide (PCA) Level II Services to 12 hours per day - 7 days per week, 12 hours per day - 7 days per week - for a total of 168 hours per week (split shift).
The denial is overturned.

This male patient has conditions including progressive cerebellar degeneration.  He is status post hip fracture and is awaiting discharge home pending approval for 24 hour care.  He lives alone in a one bedroom apartment.  He is appealing denial of increase personal care aide (PCA) services for a total of 168 hours per week.  The health plan approved 84 hours per week.  

Uniform Assessment Systems (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, and locomotion; maximal assistance with bathing, lower body dressing, walking, and toileting; extensive assistance with personal hygiene, upper body dressing, bed mobility and eating; and limited assistance with phone use. Compared to Uniform Assessment Systems (UAS) evaluation completed previously, there has been a decline is functioning with personal hygiene, lower body dressing toileting, bathing, walking, eating and bed mobility.  

An appeal letter from the provider notes the patient has progressive cerebellar degeneration.  His physical coordination, gait, balance and speech have deteriorated.  He is a fall risk, has difficulty holding objects and communication via speech.  He fell and broke his hip during hours without home health.  

An appeal statement from New York State notes the patient is status post hip fracture and has progressive cerebellar degeneration.  His functional status has declined since the hip fracture.  He requires nighttime assistance with turning, positioning every three to four hours and toileting.

Yes, the proposed treatment, Increase Personal Care Aide (PCA) Level II Services to 12 hours per day - 7 days per week, 12 hours per day - 7 days per week - for a total of 168 hours per week (split shift), is medically necessary.

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.  This patient has progressive cerebellar degeneration and is status post a recent hip fracture.  He is currently in a skilled nursing facility (SNF).  He is appealing denial of increase in personal care aide (PCA) services for a total of 168 hours per week.  The health plan approved 84 hours per week.  

UAS evaluation completed shows the patient requires assistance with all activities of daily living (ADLs).  Compared to Uniform Assessment Systems (UAS) evaluation completed previously, there has been a decline is functioning with personal hygiene, lower body dressing toileting, bathing, walking, eating and bed mobility.  Appeal statements note the patient has a progressive condition and needs 24-hour assistance to include assistance with turning, positioning and toileting.  This patient has significant cognitive and physical impairments that have progressed within the last six months.  This patient's needs for assistance with daytime and nighttime activities of daily living (ADLs) and personal care cannot be met with the approved personal care aide (PCA) 84 hours per week.  The proposed increase in personal care aide (PCA) to a total 168 per week is medically necessary and appropriate to meets this patient's needs.