Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Below knee amputation, diabetes, coronary artery disease, cardiomyopathy, and hypertension
Treatment: Increase in Personal Care Aide (PCA) Service for a Total Amount of 168 Hours/Week
The insurer denied an increase in PCA service for a total amount of 168 hours/week.
The denial is partially overturned.

The patient is an elderly female. Her conditions include right BKA (below knee amputation), diabetes, coronary artery disease, cardiomyopathy, and hypertension. Denial of increase in personal care aide (PCA) service for a total amount of 168 hours/week is being appealed. The health plan approved 84 hours/week. Additional hours are being requested for overnight assistance for fall risk and toileting.

Uniform Assessment System (UAS) evaluation completed this year shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances and medications, shopping, bathing, lower body dressing, walking, locomotion, and toileting; extensive assistance with personal hygiene, upper body dressing and bed mobility; and independent with eating. She has frequent bladder incontinence. Compared to UAS evaluation completed 6 months earlier, there has been a decline with toilet use.

Appeal statements note the patient lives alone. She is at high risk for falls. She has limited mobility and requires help and supervision at night with getting out of bed and putting on prosthesis. She is homebound due to weakness.

The requested increase in PCA service for a total amount of 168 hours/week is medically necessary, in part.

Personal care service (PCS) is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift PCS is uninterrupted care, by more than one PCA, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase in PCA service for a total amount of 168 hours/week is being appealed. The health plan approved 84 hours/week. 

Additional hours are being requested for overnight assistance for fall risk and toileting. This patient has multiple chronic conditions. UAS evaluation completed this year shows the patient requires assistance with all ADLs (activities of daily living), except eating. She is incontinent of bowel and bladder. She has frequent bladder incontinence. Compared to UAS evaluation completed 6 months earlier, there has been a decline with toilet use. Appeal statements note the patient has limited mobility and is homebound. She needs nighttime assistance with getting out of bed and toileting. 

The information provided shows that this patient has significant limitations in functioning. The approved PCA 84 hours/week is insufficient to meet this patient's needs for assistance with ADLs. However, the information does not support that the patient has continuous needs that necessitate PCA 168 hours/week. PCA at 91 hours/week is medically necessary to meet this patient's needs.