Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End-stage renal failure, diabetes, anemia, hearing loss, bilateral hip pressure ulcers, and dementia
Treatment: Increase in Personal Care Aide (PCA) Level 2: 12 hours/day, 7 days/week, for a total of 84 hours/week
The insurer denied the increase in PCA Level 2: 12 hours/day, 7 days/week, for a total of 84 hours/week.
The denial is overturned.

The patient is a male. His conditions include end-stage renal failure, diabetes, anemia, hearing loss, bilateral hip pressure ulcers, and dementia. He lives with his wife. The patient receives Social Day Care In-Home services three days per week. At issue is the denial of an increase in personal care aide (PCA) to 12 hours/day, 7 days/week, for a total of 84 hours/week. The plan approved PCA 8 hours/day, 7 days/week, for a total of 56 hours/week (the hours were increased from 35 to 56 hours per week).

The patient's Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, and managing finances; maximal assistance with managing medications, phone use, bathing, lower body dressing, walking, locomotion, and toilet transfer; and extensive assistance with personal hygiene, upper body dressing, toilet use, bed mobility and eating. He has frequent bowel and bladder incontinence. Compared to UAS evaluation completed previously, there is no significant change in functional status. Durable medical equipment includes walker, shower chair, shower grab bar, walker (seated rollator), and wheelchair.

An appeal statement notes the patient's dementia has worsened. His wife is sole caregiver when PCA is not present and is at her breaking point. His daughter lives out of state. He had two recent falls.

There are notes on prescription forms stating the patient is wheelchair dependent, needs total care, and needs 12 hours of home service.

A letter from the patient's daughter notes that the patient's condition has deteriorated over recent weeks. He is no longer able to walk and is wheelchair bound. He has developed bedsores.

Yes, the increase in PCA hours to 84 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. This patient has multiple chronic conditions, including progressive dementia. Denial of an increase in PCA to 12 hours/day, 7 days/week, for a total of 84 hours/week is being appealed. The plan approved PCA 8 hours/day, 7 days/week, for a total of 56 hours/week (PCA hours were increased from 35 to 56 hours/week).

UAS evaluation completed shows the patient requires extensive assistance to total dependence with all ADLs. He has bowel and bladder incontinence. Appeal statements note the patient has deterioration in dementia and functioning to being unable to ambulate and becoming wheelchair bound. He is unable to transfer without assistance. He has developed bed sores. This patient has significant cognitive and physical impairments. Due to deterioration in the patient's condition, the approved PCA 56 hours/week is insufficient to meet the patient's needs for assistance with ADLs and personal care. The proposed increase in PCA to total 84 hours/week is medically necessary.

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