Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity, memory decline, right toe amputation, and bowel and bladder incontinence
Treatment: Personal Care Assistance Services, an additional 30 hours per week, For a Total of 66 Hours Per Week
The insurer denied the Personal Care Assistance Services, an additional 30 hours per week, For a Total of 66 Hours Per Week.  The denial is overturned.

The patient is a male. His conditions include obesity, memory decline, right toe amputation, and bowel and bladder incontinence. Denial of personal care assistance (PCA) services, an additional 30 hours per week, for a total of 66 hours per week, is being appealed. The health plan approved PCA (personal care assistance) services for a total of 43 hours per week.

The patient's daughter notes the patient cannot be left alone due to cognitive decline. The patient lives with his daughter and son-in-law. The daughter states she is unable to continue to provide supportive care due to her own health issues, and the son-in-law works.

The appeal statement requests PCA (personal care assistance) 9 hours per day. Notes the aide hours end at 3, but help is still needed with ADLs (activities of daily living) and personal care. The request is for help from 8-4 or 8-5.

Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with housework, managing finances, stairs, and shopping; maximal assistance with meal preparation, managing finances and medication, phone use, bathing, upper body dressing, and toilet use; extensive assistance with personal hygiene, lower body dressing, walking, locomotion, toilet transfer, and bed mobility; and supervision with eating. The patient uses a walker for assistance indoors and a wheelchair for assistance outdoors. He has frequent bladder incontinence and infrequent bowel incontinence.

Yes, the requested personal care assistance service 66 hours/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 PCA (personal care assistance) services, an additional 30 hours per week, for a total of 66 hours per week. The health plan approved PCA (personal care assistance) services for a total of 43 hours per week.

This patient has multiple chronic medical conditions, including memory decline. UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living), except eating. Other ADLs (activities of daily living) and personal care require extensive assistance to total dependence. He has frequent bladder incontinence and infrequent bowel incontinence. The patient has lost the informal support of his daughter due to her medical conditions. This patient requires significant assistance with ADLs (activities of daily living) and personal care needs. With lack of informal support, these needs cannot be met with the approved PCA (personal care assistance) services for a total of 43 hours per week. The proposed increase in PCA (personal care assistance) for a total of 66 hours per week is medically necessary.

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