Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, neuropathy, hypertension, anxiety, depression and bipolar disorder, and dementia
Treatment: Increase Personal Care Assistance (PCA) Services to 35 Hours per Week
The insurer denied: Increase Personal Care Assistance (PCA) Services to 35 Hours per Week
The denial is upheld.

This elderly male has medical conditions that include osteoarthritis, neuropathy, hypertension, anxiety, depression and bipolar disorder, and dementia. He lives alone. His son assists on the weekends. The denial of an increase in personal care assistance (PCA) services to 35 hours per week is being appealed. The health plan approved personal care assistance three hours per day - four days per week - for a total of 12 hours per week. The Uniform Assessment System (UAS) evaluation completed six months ago shows minimally impaired condition and functional status: maximal assistance with housework and managing medications; extensive assistance with meal preparation; limited assistance with transportation; supervision with managing finances, bathing, personal hygiene, dressing, walking, locomotion, and toileting; and independent with bed mobility and eating. The patient is continent of bowel and bladder. Compared to Uniform Assessment System evaluation completed last year, there has been no significant change. 
An appeal letter from the patient's sister notes the patient has morning bouts of anxiety and his mobility is less stable. Additional help is requested to keep him safe. An appeal statement from 
the patient's provider notes there has been a decline in the patient's behavioral ability and cognitive functioning over the past year. He has progressive moderate to severe dementia impacting his ability to functioning independently. He requires oversight and assistance with medications.

The requested health service is not 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. This patient has medical conditions that include moderate to severe dementia. The denial of an increase in personal care assistance (PCA) services to 35 hours per week is being appealed. The health plan approved personal care assistance three hours per day - four days per week - for a 
total of 12 hours per week. Uniform Assessment System (UAS) evaluation completed six months ago shows the patient requires assistance with housework, managing medications, meal preparation, and transportation. Compared to Uniform Assessment System evaluation completed last year, there has been no significant change. The patient is continent of bowel and 
bladder. Appeal letters report the patient's behavioral ability and cognitive functioning have declined. His dementia impacts his ability to function independently. The information provided does not support that the patient has functional needs requiring personal care assistance 35 hours per day. Personal care assistance is not indicated for supervision or when no tasks are being performed. The approved personal care assistance 12 hours per week is appropriate to meet this patient's needs for assistance with activities of daily living. The proposed personal care assistance 35 hours per week is not indicated.