Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis, legal blindness, hypertension, and gout.
Treatment: Increase Personal Care Aide (PCA) Services For A Live-in Per Diem 24 Hours Per Day 7 Days Per Week.
The insurer denied the Increase Personal Care Aide (PCA) Services For A Live-in Per Diem 24 Hours Per Day 7 Days Per Week.
The denial is overturned.

The patient is a male. His conditions include arthritis, legal blindness, hypertension, and gout. He was recently hospitalized with sepsis and transferred to rehab. Denial of increase personal care aide (PCA) services for a live-in per diem 24 hours per day, 7 days per week, is being appealed. The health plan approved 56 hours per week.

Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances and medications, shopping, bathing, personal hygiene, dressing, walking, locomotion, and toileting; extensive assistance with phone use and bed mobility; and limited assistance with eating. The patient has frequent bowel and bladder incontinence. UAS (Uniform Assessment System) evaluation completed compared to previous evaluation shows functional decline with upper body dressing, personal hygiene, toileting, walking, locomotion, and eating.

A letter from the patient's provider notes that the patient is unable to care for himself. The letter notes that the patient needs 24/7 care and supervision due to chronic conditions. He is not cognitive of his surroundings and has limited mobility.

Yes, the requested increase in personal care aide to 24/hours day, 7 days/week, live-in, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
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 PCA (Personal Care Aide) services for a live-in per diem 24 hours per day, 7 days per week, is being appealed. The health plan approved 56 hours per week.

The patient has several chronic conditions. He was recently hospitalized with sepsis and transferred to rehab. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). UAS (Uniform Assessment System) evaluation completed compared to previous evaluation shows functional decline with upper body dressing, personal hygiene, toileting, walking, locomotion, and eating. The patient has frequent bowel and bladder incontinence. An appeal letter from the provider notes the patient has limited cognition and mobility resulting in need for 24/7 care. This patient has significant cognitive and physical impairments that have progressed between UAS (Uniform Assessment System) evaluations. The approved PCA (Personal Care Aide) 56 hours per week is inadequate to meet the patient's needs for assistance with ADLs (activities of daily living)/IADLs (instrumental activities of daily living). The proposed increase in PCA (Personal Care Aide) services for a live-in per diem 24 hours per day, 7 days per week is medically necessary.