Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, rotator cuff tear, hypertension, diabetes, pedal edema, neuropathy, osteoporosis, adjustment disorder, major depression, and anxiety
Treatment: Personal Care Services, Level II, 7 Hours per Day, 7 Days per Week, for a Total of 49 Hours per Week
The insurer denied: Personal Care Services, Level II, 7 Hours per Day, 7 Days per Week, for a Total of 49 Hours per Week
The denial is Overturned

This elderly female has conditions including osteoarthritis, rotator cuff tear, hypertension, diabetes, pedal edema, neuropathy, osteoporosis, adjustment disorder, major depression, and anxiety. She lives with her son and daughter-in-law. Denial of personal care services 7 hours per day, 7 days per week, for a total of 49 hours per week is being appealed. The plan approved 4.5 hours per day, 7 days per week, for a total of 31.5 hours per week. Uniform Assessment System (UAS) evaluation completed 4 months ago shows modified independent cognition and functional status: maximal assistance with meal preparation, 
housework, and shopping; extensive assistance with stairs, transportation, bathing, and lower body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toileting; and independent with bed mobility and eating. She has frequent urinary incontinence. She ambulates with a walker. Compared to Uniform Assessment System evaluation completed last year, there has been a functional decline with bathing and lower body dressing. A letter from the Provider notes the patient has rapidly deteriorating cognitive and physical health. Since the passing of her spouse, she has emotional liability, anhedonia, and insomnia. She sleeps in a seated position. She has post-COVID fog and progressive short term memory loss. She requires supervision and assistance with activities of daily living as well as multiple daily changes of diapers. A letter from the patient's designee notes the patient needs assistance with activities of daily living (ADLs). She has changed post COVID. She is left for extended hours in a soiled diaper.

The proposed treatment 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. This patient has multiple chronic conditions, including post-COVID symptoms. The denial of personal care services 7 hours per day, 7 days per week, for a total of 49 hours per week is being appealed. The plan approved 4.5 hours per day, 7 days per week, for a total of 31.5 hours per week. The health plan denied increasing hours because the two Uniform Assessment System evaluations show the patient qualifies for 26 hours. Her social and living conditions have not changed. There is no significant change in her medical conditions. Services are not provided for safety and supervision. However, Uniform Assessment System evaluation completed 4 months ago shows the patient requires assistance with all activities of daily living, except bed mobility and eating. Compared to Uniform Assessment System evaluation completed last year, there has been a functional decline with bathing and lower body dressing. The appeal statements note there has been a progressive decline in the patient's physical and cognitive functioning since having COVID-19. The patient needs assistance with all activities of daily living (ADLs) as well as multiple daily changes of diapers. The information provided shows that this patient has significant limitations in functioning. She is reported to have declined since COVID. The approved personal care services of 31.5 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 49 hours per week is medically necessary.