Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, diabetes. 
Treatment: Increase Personal Care Aide (PCA) Services to five hours per day, six days a week, for a total of 30 hours per week. 

The insurer denied the Increase Personal Care Aide (PCA) Services to five hours per day, six days a week, for a total of 30 hours per week. 

The denial is upheld. 

This female has medical conditions including osteoarthritis, diabetes, hypertension, and coronary artery disease (CAD).  She lives alone.  This is an appeal of denial of an increase personal care aide (PCA) services from five hours per day, three days a week, a total of 15 hours per week to five hours per day, six days a week, for a total of 30 hours per week.  The patient is requesting an increase due to pain in her back and hands.  Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation and shopping; limited assistance with managing finances and medications, toilet use, bathing, personal hygiene, and dressing; and supervision with walking, locomotion, toilet transfer and bed mobility.  She is continent of bowel and bladder.  Compared to Uniform Assessment System (UAS) evaluation completed previously, it shows not change in functional status. 

Appeal letter from the provider states the patient had difficulty remembering her daily medications.  A prescription note from another provider states the patient will benefit from additional hours due to worsening of hip, back and knee pain. 

No, the proposed treatment is not 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 osteoarthritis. This is an appeal of denial of an increase personal care aide (PCA) services from five hours per day, three days a week, a total of 15 hours per week to five hours per day, six days a week, for a total of 30 hours per week due to an increase in hand and back pain.  Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with housework, meal preparation, shopping, managing finances and medications, toilet use, bathing, personal hygiene, and dressing.  Other than assistance with housework, preparation and shopping, the patient requires limited assistance with the activities of daily living (ADLs) / instrumental activities of daily living (IADLs), as noted above.  Compared to Uniform Assessment System (UAS) evaluation completed previously, it shows not change in functional status.  Appeal statements note the patient needs assistance due to pain as well as remembering medications.  Uniform Assessment System (UAS) evaluations show no significant change in the patient's functional status.  Personal care aide is not indicated for supervision or when no tasks are being performed.  The approved personal care aide 15 hours per week is appropriate and medically indicated to meet this patient's needs for assistance with activities of daily living (ADLs) / instrumental activities of daily living (IADLs).  The proposed increase in personal care aide to 30 hours per week is not medically necessary.