Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, blindness due to macular degeneration, and a hearing impairment. 
Treatment: Increase Personal Care Aide (PCA) Services for a Live-in Per Diem (24 hours per day). 

The insurer denied the Increase Personal Care Aide (PCA) Services for a Live-in Per Diem (24 hours per day). 
The denial is overturned. 

The patient is a male. His conditions including dementia, blindness due to macular degeneration, and a hearing impairment. He lives with his spouse. This is an appeal of denial of increase personal care aide (PCA) services for a live-in, 24 hours per day. The Plan increased hours from 42 to 49 hours per week. His son notes that the patient has failed and was recently hospitalized due to syncope. Notes he needs assistance with transfers and cannot function independent. Notes the patient has bowel incontinence and a permanent urinary catheter. The patient does not have informal support.

UAS (Uniform Assessment System) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, and locomotion; maximal assistance with managing medications, phone use, transportation, bathing, personal hygiene, dressing, walking, toilet use, and bed mobility; and extensive assistance with eating. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with meal preparation, phone use, bathing, personal hygiene, dressing, toileting, bed mobility, and eating. 

A letter from a provider notes there has been a steep decline in the patient's functioning. Notes the patient needs total care with all ADLs (activities of daily living). He has bowel incontinence and is unaware. He awakens 4-5 times per night and needs hands on help when he attempts to get out of the bed. 

A letter from the patient's son notes the patient will no longer have informal support. He is unable to get out of bed without assistance. Notes the patient needs full assistance with ADLs (activities of daily living). 

An appeal letter notes the patient needs assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation. Notes the patient requires more than stand-alone safety monitoring and recommends 24 hour care. 

Yes, the requested Increase Personal Care Aide (PCA) Services for a Live-in Per Diem (24 hours per day) 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 ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase personal care aide (PCA) services for a live-in, 24 hours per day is being appealed. The Plan increased hours from 42 to 49 hours per week. 

This patient has conditions including progressive dementia and weakness. UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). Other than extensive assistance with eating, the patient requires maximal to total assistance with all ADLs (activities of daily living). Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a significant decline in functional status with meal preparation, phone use, bathing, personal hygiene, dressing, toileting, bed mobility, and eating. It is noted that the patient's functional status deteriorated after hospitalization. He is incontinent of bowel and has a urinary catheter. Appeal statements note that the patient's cognitive and functional status have declined and requires assistance with all ADLs (activities of daily living). The patient awakens during the night and requires assistance with bed transfers. The patient had overnight informal support, which is no longer available. This patient requires significant assistance with all ADLs (activities of daily living) and personal care, including transferring, locomotion, and locomotion. The approved PCA (personal care aide) 49 hours per week are insufficient to meet this patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase in PCA (personal care aide) live-in, 24 hours per day is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.