Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastric cancer, status post gastronomy, anxiety, insomnia, acute kidney injury, and hypertension
Treatment: Increase PCA Hours To 7 Days Per Week, 12 Hours Per Day a Total 84 Hours Per Week
The insurer denied: Increase PCA Hours To 7 Days Per Week, 12 Hours Per Day a Total 84 Hours Per Week
The denial is overturned.

The patient is an elderly male. His diagnoses include gastric cancer, status post gastronomy, anxiety, insomnia, acute kidney injury, and hypertension. He was hospitalized for 3 months last year due to gastric cancer. Denial of increase personal care aide (PCA) hours to 7 days per week, 12 hours per day a total 84 hours per week is being appealed. The health plan partially 
approved personal care aide (PCA) increase from 42 to 56 hours per week (8 hours/day, 7 days a week). The patient's Uniform Assessment System (UAS) evaluation completed 3 months ago shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications; extensive assistance with phone use, bathing, and lower body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toileting; and independent with bed mobility and eating. He ambulates with a walker. He has bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been a decline in functional status with meal preparation, housework, managing medications and finances, and shopping. A letter from the patient's provider reports that the patient was admitted to a nursing home for short-term rehab 5 months ago. The patient has had decline in medical, cognitive, and functional status, requiring assistance with all activities of daily living (ADLs). He is homebound. He has increased episodes of confusion and anxiety throughout the day and night. 
Increase in home care hours is recommended for appropriate care and safety measures on a constant basis. An appeal letter reports that the patient has gastric cancer and related complications. He cannot get out of the bed on his own. He ambulates with a walker, and he has poor safety awareness. He 
needs assistance with food set up, diaper changes due to incontinence, repositioning, and dressing. He is in bed for 16 hours with a soiled diaper and no food.

The requested Increase in PCA (personal care aide) Hours To 7 Days Per Week, 12 Hours Per Day, 84 Hours Per Week, 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. Denial of increase personal care aide hours to 7 days per week, 12 hours per day a total 84 hours per week is being appealed. The health plan partially approved personal care aide from 42 to 56 hours per week (8 hours/day, 7 days a week). This patient has a history of gastric cancer and was recently hospitalized due to this condition. He is currently in a nursing home. Uniform Assessment System (UAS) evaluation completed 3 months ago shows he is dependent with all activities of daily living, except bed mobility and eating. There has been no significant change in activities of daily living compared to Uniform Assessment System evaluation completed 6 months ago. He has bowel and bladder incontinence. The appeal statement reports a decline in medical, cognitive, and functional status, and need for assistance with all activities of daily living. He is unable to get out of the bed and needs assistance with ADLs (activities of daily living), including diaper changes and repositioning. Increase in home care hours is recommended for appropriate care and safety measures on a constant basis. The information provided supports that the patient has significant impairments with completing ADLs (activities of daily living). The lack of adequate hours results in his being bed bound with a soiled diaper for most of the hours in a day. The partially approved personal care aide 56 hours per week is inadequate to meet this patient's needs for assistance with activities of daily living. The requested increase in personal care aide to 84 hours per week is medically necessary.