Appeal type: Medical necessity
Decision: Overturned

Diagnosis: status post COVID-19, hypertension, osteoarthritis, major depressive disorder, deteriorating memory, and legally blind.
Treatment: Increase Personal Care Aide (PCA) For a Total of 56 Hours Per Week.
The insurer denied the Increase Personal Care Aide (PCA) For a Total of 56 Hours Per Week.
The denial is overturned.

The patient is a female. Her conditions include status post COVID-19, hypertension, osteoarthritis, major depressive disorder, deteriorating memory, and legally blind. She lives alone. Denial of increase personal care aide (PCA) for a total of 56 hours per week, is being appealed. The health plan approved PCA (personal care aide) 5.5 hours per day, 7 day per week for a total of 38.5 hours per week.

Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing medications, shopping, bathing, lower body dressing, walking, and locomotion; extensive assistance with managing finances, personal hygiene, upper body dressing, toileting, bed mobility, and eating; and limited assistance with phone use. She has occasional bladder incontinence. UAS (Uniform Assessment System) evaluation compared to previous evaluation shows decline in functional status with cognition, upper body dressing, personal hygiene, lower body dressing, toilet use, bathing, walking, locomotion, eating, and bed mobility.

A letter from the patient's provider notes the patient has conditions including status post COVID-19, hypertension, osteoarthritis, major depressive disorder, deteriorating memory, headaches and dizziness, and unsteady balance. Her psychological status has been deteriorating since COVID. She is unable to ambulate without assistance. She is unsafe due to dizziness. She is especially depressed and anxious when left alone.

A letter from another provider notes the patient has rapidly deteriorating physical health and functional status. Her medical conditions include age-related cognitive decline. She requires assistance with all ADLs (activities of daily living).

Yes, the Increase Personal Care Aide (PCA) For a Total of 56 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.
Personal Care 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 in PCA (personal care aide) services for a total of 56 hours per week, is being appealed. The health plan approved PCA (personal care aide) 5.5 hours per day, 7 day per week for a total of 38.5 hours per week.

The patient has several chronic conditions including recent COVID-19 infection. She lives alone. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). She has bladder incontinence. UAS (Uniform Assessment System) previous evaluation compared to most recent shows decline in functional status with cognition, upper body dressing, personal hygiene, lower body dressing, toilet use, bathing, walking, locomotion, eating, and bed mobility. Appeal letters show the patient has deteriorated since COVID infection and needs assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation. This patient has significant physical impairments that have progressed between UAS (Uniform Assessment System) evaluations. Based on this progression and her level of assistance needed, the approved 38.5 hours per week is inadequate to meet the patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living). The requested increase in PCA (personal care aide) to a total 56 per week is medically necessary.