Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Legal blindness, asthma, chronic pain, and age-related cognitive decline. 
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week. 
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week. 
The denial is upheld. 

The patient is an elderly female patient that has medical conditions that include legal blindness, asthma, chronic pain, and age-related cognitive decline. She lives alone. The denial of an increase in personal care aide (PCA) services for a total amount of 168 hours per week is under review. The health plan approved a total of 59.5 hours per week. Uniform Assessment System (UAS) evaluation completed 3 months ago shows moderately impaired cognition and functional status and requires maximal assistance to total dependence with all activities of daily living (ADLs). She has frequent bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline to need for total assistance with personal hygiene, locomotion, and eating. A letter from the patient's daughter-in-law notes the patient had several falls. She is totally dependent for mobility and transfer. She has bowel incontinence and requires diaper changes. She cannot be left alone due to danger posed. A letter from a Provider notes the patient is homebound. She needs assistance with activities of daily living. Her medical conditions are at risk of worsening without additional assistance. 

The requested health service is not 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. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions, including legal blindness. Denial of an increase in personal care aide (PCA) services for a total amount of 168 hours per week is under review. The health plan approved a total of 59.5 hours per week. Uniform Assessment System (UAS) evaluation completed 3 months ago shows the patient requires maximal assistance to total dependence with all activities of daily living. She has frequent bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline to need for total assistance with personal hygiene, locomotion, and eating. The appeal statements support the patient is dependent with activities of daily living and needs assistance with mobility due to blindness. A statement notes that the patient's medical conditions are at risk of worsening without additional assistance. The information provided does not support that the patient has need for continuous care. Personal care services are not indicated for management of medical conditions. The patient does not require frequent assistance with toileting, transfers, and turning/repositioning that would not allow an aide five hours daily of uninterrupted sleep during the aide's shift. The proposed personal care aide services for a total of 168 hours per week are not medically indicated.