Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary heart disease, chronic kidney disease, cerebral vascular accident, polymyalgia rheumatic, sciatica, osteoarthritis, and lumbar radiculopathy.
Treatment: Increase Personal Care Services (PCS) for 12 Hours a Day, 7 Days per Week for a Total of 84 Hours
The insurer denied:  Increase Personal Care Services (PCS) for 12 Hours a Day, 7 Days per Week for a Total of 84 Hour
The denial is overturned

The patient is an elderly female. Her medical conditions include coronary heart disease, chronic kidney disease, cerebral vascular accident, polymyalgia rheumatic, sciatica, osteoarthritis, and lumbar radiculopathy. She lives alone. Denial of increase personal care services (PCS) for 12 hours a day, 7 days per week for a total of 84 hours is being appealed. The health plan approved personal care services 8 hours a day, 7 days a week for a total of 56 hours.
Uniform Assessment System (UAS) evaluation completed six months ago shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, bathing, dressing, walking, locomotion, and toileting; extensive assistance with managing finances and medications, phone use, personal hygiene, and bed mobility; and limited assistance with eating. The patient had a recent fall after rolling out of the bed onto the floor. She has frequent bladder incontinence. Compared to UAS (uniform assessment system) evaluation 12 months ago, there has been a decline with function with housework, dressing, walking, locomotion, and bed mobility. And appeal letter from legal services notes that the patient is homebound. The patient is unable to perform ADLs (activities of daily living) due to shoulder pain. Her medical conditions have worsened. She requires assistance with ADLs (activities of daily living) as already accounted for in the UAS (uniform assessment system) evaluation.
A letter from the patient's provider notes the patient is homebound due to her unsteady gait, imbalance, dizziness and use of walker. The patient is dependent on others for ADLs (activities of daily living). Due to her cognitive impairment, she requires cueing with ADLs (activities of daily living).
Office notes have been provided supporting the patient's chronic medical conditions.

The requested Increase Personal Care Services (PCS) for 12 Hours a Day, 7 Days per Week for a Total of 84 Hours 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 services (PCS) for 12 hours a day, 7 days per week for a total of 84 hours is being appealed. The health plan approved personal care services 8 hours a day, 7 days a week for a total of 56 hours per week.
The patient has multiple chronic conditions. She lives alone. Uniform Assessment System (UAS) evaluation completed 6 months ago shows the patient needs assistance with all ADLs (activities of daily living). She has frequent bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline with function with 
housework, dressing, walking, locomotion, and bed mobility. She has frequent bladder incontinence.  There has been a decline with function with housework, dressing, walking, locomotion, and bed mobility. The appeal statements and clinical records support the multiple medical conditions and need for assistance with ADLs (activities of daily living). The information provide show that this patient has significant limitations in functioning. The need for assistance with all ADLs (activities of daily living) cannot be met with the approved personal care services 8 hours a day, 7 days a week for a total of 56 hours. The requested increase PCS (personal care service) to 12 hours a day, 7 days per week for a total of 84 hours is medically necessary.