Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, diabetes, kidney disease, heart
disease, peripheral vascular disease, decreased
hearing and decreased vision
Treatment: Increase Personal Care Services from Four Hours a Day, Six Days a Week To Eight Hours a Day, Six Days a Week
The insurer denied the Increase Personal Care Services from Four Hours a Day, Six Days a Week To Eight Hours a Day, Six Days a Week
The denial is overturned.

This male has medical conditions including hypertension, diabetes, kidney disease, heart disease, peripheral vascular disease, decreased hearing and decreased vision.  He lives alone.  He is appealing denial of increase in Personal Care Services from four hours a day, six days a week to eight hours per day, six days a week.  

Uniform Assessment System (UAS) evaluation completed notes the patient has modified independent cognition and functional status: maximal assistance with housework and shopping; extensive assistance with meal preparation; limited assistance with managing finances and medications, and bathing; supervision with personal hygiene, dressing, walking, locomotion, toileting and eating; and independent with bed mobility.  He is continent.  Compared to Uniform Assessment System (UAS) evaluation completed previously, there has been a decline in the ability to perform housework, shopping, and bathing.  He was independent with bathing; supervision with personal hygiene, dressing, walking, locomotion, toileting and eating but now requires supervision.  

Appeal letter from NY (New York) State notes the patient was hospitalized after falling in his home due to hypoglycemia.  It states the patient's needs for assistance with activities of daily living (ADLs) have increased since hospitalization.  It states that per the patient's daughter, the Uniform Assessment System (UAS) evaluation does not adequately portray the patient's decline. It notes the current hours do not allow enough time for managing medications and meal preparation.  It states the patient requires weight bearing assistance due to leg weakness and lack of balance.  He holds on to the aide and uses a cane when transferring.  A letter dated from the provider notes the patient's medical conditions have worsened and the current plan of care is insufficient to meet his needs.  A letter dated for his housing notes the patient had three falls and has concerns that the patient cannot complete activities of daily living (ADLs) without additional assistance.

Yes, 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.  He was hospitalized after falling.  He is appealing denial of increase Personal Care Services from four hours a day, six days a week to eight hours per day, six days a week.  Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with housework, shopping, meal preparation, managing finances and medications, and bathing; and supervision with personal hygiene, dressing, walking, locomotion, toileting and eating.  Compared to Uniform Assessment System (UAS) evaluation completed previously, there has been a decline in physical functioning with housework, shopping, bathing, personal hygiene, dressing, walking, locomotion, toileting and eating.  The appeal statements note that the patient's functional status has declined since hospitalization.  It is indicated that the Uniform Assessment System (UAS) evaluation, which was telephonic, does not accurately reflects the patient's level of functioning noting the patient requires weight bearing assistance with transfers and more time for housework and meal preparation.  The aide has been unable to complete meal preparation and manage evening medications due to insufficient hours.  This patient requires significant assistance with activities of daily living (ADLs).  Based on the patient's decline and current functional status, the proposed personal care services (PCS) four hours a day, six days a week is insufficient to meet this patient's needs for assistance with activities of daily living (ADLs) / instrumental activities of daily living (IADLs).  The proposed increase to personal care services eight hours per day, six days a week is medically necessary.

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