Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), hypertension, obesity, vertigo, 
trigger finger, hip osteoarthritis, chronic shoulder pain, lumbar radiculopathy, and type 2 diabetes
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 40 Hours Per Week
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total Amount of 40 Hours Per Week
The denial is overturned.

The patient is an elderly female. Her medical conditions include chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), hypertension, obesity, vertigo, trigger finger, hip osteoarthritis, chronic shoulder pain, lumbar radiculopathy, and type 2 diabetes. Denial of increase personal care aide (PCA) services for a total amount of 40 hours per week is being appealed. The health plan approved PCA (personal care aide) 5 hours per day, 5 days per week, for a total of 25 hours per week.
The patient's Uniform Assessment System (UAS) evaluation completed 6 months ago shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing medications, and shopping; extensive assistance with bathing, personal hygiene, dressing, walking locomotion, and toileting; limited assistance with bed mobility; supervision with managing finances; and independent with phone use and eating. She has frequent bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with cognition, upper body dressing, personal hygiene, toilet use, walking, and locomotion. A letter from the patient's provider reports the patient has progressive chronic medical conditions that prevent her from maintaining activities of daily living. The patient does not have informal support. A letter from the patient's daughter reports that osteoarthritis affects the patient with lifting her arm and imbalance. She needs assistance with bathing, dressing, and stairs. The patient recently went to the emergency room with home attendant with time extending beyond the attendant's shift. An appeal letter reports the patient needs assistance with activities of daily living due to her multiple conditions. It notes that the hours should be increased based on the recommendations from the primary care physicians.

The requested Increase in Personal Care Aide (PCA) Services for a Total Amount of 40 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 (PCA) services for a total amount of 40 hours per week is being appealed. The health plan approved personal care aide 5 hours per day, 5 days per week, for a total of 25 hours per week. This patient has multiple chronic conditions, primarily including osteoarthritis. Uniform Assessment System (UAS) evaluation completed 6 months ago shows the patient requires assistance with all activities of daily living, except managing finances, phone use, and eating. She has frequent bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with cognition, upper body dressing, personal hygiene, toilet use, walking, and locomotion. Appeal statements report the patient needs additional personal care aide hours due to multiple chronic conditions that affect her ability to 
perform activities of daily living. She lives alone and does not have informal support. The information provided shows that this patient has significant limitations in functioning that have progressed between Uniform Assessment System evaluations. The approved personal care aide 25 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The requested increase to 40 hours per week is medically necessary.