Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebellar ataxia.
Treatment: Increase Personal Care Aide Hours From 7 Days A Week 8 Hours A Day to 7 days Week, 10 Hours A Day.
The insurer denied the Increase Personal Care Aide Hours From 7 Days A Week 8 Hours A Day to 7 days Week, 10 Hours A Day.
The denial is overturned.

The patient is a male. He has cerebellar ataxia diagnosed during adolescence. He lives with his mother. Denial of increase personal care aide (PCA) hours from 7 days a week 8 hours a day to 7 days week, 10 hours a day, is being appealed.

Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation and shopping; extensive assistance with managing finances and medications, bathing, lower body dressing, and toileting; limited assistance with personal hygiene, upper body dressing, walking, and locomotion; supervision with eating; and independent with phone use and bed mobility. Compared to UAS (Uniform Assessment System) evaluation completed on previously, there has been no significant decline in functioning.

An appeal statement notes the patient has unscheduled needs, and due to a change in social circumstances, his needs are not being met with the current hours. Notes that a letter from his provider notes the patient is wheelchair and walker dependent. The patient has progressively lost the ability to care for himself. Additional hours are requested because two family members that provided assistance have moved out.

A letter from the patient's mother states her work hours have increased and her two other children moved out. Being the only caregiver, she is not able to meet his needs and work her full-time job.

A letter from the patient's provider notes the patient's condition is progressive and he has had a recent decline in motor functioning. In addition, he has less help from family.

Yes, the Increase Personal Care Aide Hours From 7 Days A Week 8 Hours A Day to 7 days Week, 10 Hours A Day 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 PCA (personal care assistance) hours from 7 days a week 8 hours a day to 7 days week, 10 hours a day, is being appealed.

This patient has progressive cerebellar ataxia. He lives with his mother and had been receiving informal support of his siblings. Uniform Assessment System evaluation completed shows the patient requires assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living), except bed mobility and eating. He requires assistive devices of a wheelchair and walker. The appeal letters note the patient's condition is progressive and he has recent decline in motor functioning. He no longer has the informal family support since his siblings have moved out of the home. This patient requires significant assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living). Due to loss of informal support, the approved PCA (personal care assistance) 7 days week, 8 hours a day is inadequate to meet the patient's needs for assistance. The proposed increase in PCA (personal care assistance) 7 days week, 10 hours a day is medically necessary to meet his needs with ADLs/IADLs (activities of daily living/instrumental activities of daily living).

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.