Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, asthma, hypertension, diabetes, chronic kidney disease, and coronary artery disease
Treatment: Increase Personal Care Aide (PCA) Services For A Total Amount of 70 Hours A Week
The insurer denied the Increase Personal Care Aide (PCA) Services For A Total Amount of 70 Hours A Week.

The denial is overturned.

The patient is a female. Her conditions including dementia, asthma, hypertension, diabetes, chronic kidney disease, and coronary artery disease. She lives alone. Denial of increase personal care aide (PCA) services for a total amount of 70 hours a week is being appealed. The health plan approved an increase from 30.5 to 40 hours/week.

Uniform Assessment System (UAS) evaluation performed shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, and toilet use; maximal assistance with managing medications, phone use, bathing, and lower body dressing; extensive assistance with personal hygiene, upper body dressing walking, locomotion, toilet transfer; limited assistance with bed mobility; and supervision with eating. She has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, cognition has declined from moderately impaired and functional status has declined with lower body dressing, walking, locomotion, toileting, and bed mobility.

An appeal statement notes the patient has a critical decline in her cognitive functioning and mobility over the past year. The patient's physician reports that the patient is bed bound and totally dependent with all ADLs (activities of daily living). She requires extensive assistance with walking. She has increased frequency of bowel and urinalysis incontinence and increased need for toilet transferring and cleaning. Her ability to make safe decisions has declined.

A progress report by the patient's physician notes the patient is bed ridden now with back pain, urinary incontinence, spoon fed and full care for all ADLs (activities of daily living). She has advanced dementia. She has nocturnal enuresis. A letter from the doctor notes the patient has no informal support. She needs assistance with ADLs (activities of daily living) and supervision of medications.

Yes, the Increase Personal Care Aide (PCA) Services For A Total Amount of 70 Hours A 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 70 hours a week is being appealed. The health plan approved an increase from 30.5 to 40 hours/week.

This patient has multiple progressive conditions, including dementia. UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living), except eating. Compared to UAS (Uniform Assessment System) evaluation completed previously, cognition has declined from moderately impaired and functional status has declined with lower body dressing, walking, locomotion, toileting, and bed mobility. She has bowel and bladder incontinence. The appeal statements indicate that the patient cognitive and functional abilities have declined to her being bed bound. She is now bed bound and requires increased assistance with transfers and increase needs for assistance with toileting due to more incontinence. This patient requires significant assistance with ADLs (activities of daily living) and personal care. She has deterioration in her functional status as per appeal statements and UAS (uniform assessment system) evaluations. The patient's needs for assistance cannot be met with the proposed PCA (personal care aide) 40 hours per week. The proposed increase in PCA (personal care aide) 70 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.