Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia CVA (cerebrovascular accident), with right-sided residual deficits, diameters, hypertension, A fib (atrial fibrillation), CHF (congestive heart failure), and anxiety/depression
Treatment: Increase in personal care aide (PCA) services - 12 hours per day, 7 days per week, 84 hours per week
The insurer denied the increase in personal care aide (PCA) services - 12 hours per day, 7 days per week, 84 hours per week.
The denial is overturned.

The patient is a female.  Her conditions include dementia, CVA (cerebrovascular accident), with right-sided residual deficits, diameters, hypertension, A fib (atrial fibrillation), CHF (congestive heart failure), and anxiety/depression.  The patient had been recently discharged from a SNF (skilled nursing facility).  Denial of increase in personal care aide (PCA) services - 12 hours per day, 7 days per week, 84 hours per week is being appealed.  She has been approved for PCA services - 9.5 hours per day, 7 days per week, 66.5 hours per week.

The patient's daughter reports the patient needs supervision at all times.  UAS (Uniform Assessment System) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, meaning finances, shopping, and locomotion; maximal assistance with managing medications, phone use, bathing, personal hygiene, dressing, walking, and eating; and extensive assistance with bed mobility.  She ambulates indoors with a walker.  She is incontinent of bowel and bladder.  Comparison of UAS evaluations performed previously shows decline in cognition, upper body dressing, personal hygiene, toileting, walking, locomotion, and eating.  The patient has a seated rollator walker, bedside commode, cane, shower chair, shower grab bar and Personal Emergency Response System (PERS) and incontinence supplies.  An appeal letter from the provider notes the patient lives alone.  The patient was admitted for short term rehab.  Since that time, there has been a decline in cognitive, functional and medical status.  The letter notes the patient requires frequent toileting and changing.  She is high fall risk.  Rehab records were included.

Yes, the increase in personal care aide to 84 hours/week is medically necessary.

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 services - 12 hours per day, 7 days per week, 84 hours per week is being appealed.  She has been approved for PCA services - 9.5 hours per day, 7 days per week, 66.5 hours per week.

The patient has several chronic conditions, including dementia and status post stroke with residual right-sided hemiplegia.  She had recently been discharged from a SNF after admission for rehab.   She lives alone.  Per UAS evaluation completed, the patient requires assistance with all ADLs.  She has bowel and bladder incontinence.  In comparison to UAS evaluations completed previously, there is decline in cognition, upper body dressing, personal hygiene, toileting, walking, locomotion, and eating.  The patient is incontinent of bowel and bladder.  The appeal letter from her doctor notes there has been a decline in the patient cognitive, functional, and medical status.  This patient has significant cognitive and physical impairments that have progressed between UAS evaluations.  The approved 66.5 hours per week are inadequate to meet the patient's needs for assistance with ADLs/IADLs (instrumental activities of daily living).  The proposed increase in PCA hours to a total of 84 per week is medically necessary and appropriate to meet this patient's needs.