Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Age-related debility, cancer, CAD (coronary artery disease), heart failure, spinal stenosis, osteoarthritis, and polymyalgia rheumatica.
Treatment: Increase In Personal Care Assistant (PCA) Services From 7 Days x 6 Hours (42 Hours Per Week) To 7 Days x 19 Hours (133 Hours Per Week), Pre-service.
The insurer denied the increase in personal care assistant (PCA) services from 7 days x (times) 6 hours (42 hours per week) to 7 days x 19 hours (133 hours per week), pre-service.
The denial is overturned.

The patient is a male with medical conditions including age-related debility, cancer, CAD (coronary artery disease), heart failure, spinal stenosis, osteoarthritis, and polymyalgia rheumatica. This is an appeal for denial of an increase in personal care assistant (PCA) services from 7 days x 6 hours (42 hours per week) to 7 days x 19 hours (133 hours per week).

UAS (Uniform Assessment System) evaluation completed shows minimally impaired cognition and functional status: total dependence with meal preparation and housework; maximal assistance with managing finances, shopping; extensive assistance with managing medications, phone use, bathing, dressing, locomotion, and toileting; limited assistance with personal hygiene and bed mobility; and independent with eating. He uses a rollator for indoor ambulation. He is frequently incontinent of bladder. There is no significant change compared to previous UAS evaluation completed.

Clinical note notes the patient is becoming weaker and memory is worsening. He has limited mobility due to osteoarthritis. Notes the patient needs 24 hours care and assistance with all ADLs (activities of daily living). A letter from the provider indicates additional hours are needed due to high risk of falls, multiple chronic medical condition, fatigue, and overnight needs for toileting, incontinence care, transfers, bed mobility and ambulation assistance. Exhibits include a nighttime log that shows assistance every two to three hours per night with toileting. An appeal letter from another provider states the patient has increased need for toileting. Notes the patient is unable to stand or take steps without assistance. He cannot self-propel wheelchair due to decreased upper extremity strength. Notes night sleep is disturbed by need for toilet and to frequently change position to alleviate pain. Advocacy report states 24 hour care is medically necessary. This report includes supporting information as already noted above.

Yes, the increase in personal care assistant service hours to 7 days x 19 hours (133 hours per week) is medically necessary.

The requested health service is consistent with generally accepted standards of medical practice.

Personal assistance services provide hands-on assistance to individuals to include: assistance with ADLs, health maintenance activities, and routine support services. This is an appeal for denial of an increase in PCA services from 7 days x 6 hours (42 hours per week) to 7 days x 19 hours (133 hours per week).

This patient has multiple chronic conditions, including age-related debility, and limited mobility due to arthritis. UAS evaluation completed shows the patient requires assistance with all ADLs/IADLs (instrumental activities of daily living) except eating. He is incontinent of bladder. Appeal statements indicate that there has been a decline in the patient's cognitive and functional status. In addition to noting need for assistance with ADLs as accounted for in the UAS evaluation, these statements indicate that the patient has nighttime needs for assistance with toileting and repositioning. There are logs provided showing the patient receiving nighttime assistance approximately every two hours. Based on this patient's needs for daytime and nighttime assistance, the approved 42 hours is insufficient to meet the patient's needs for assistance with ADLs/IADLs. The proposed increase in PCA services to 133 hours per week is medically necessary.