Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Subdural hematoma, hypothyroidism, urinary incontinence.
Treatment:  Increase personal care aide (PCA) Level II: 12 hours per day - 7 days per week - a total of 84 hours per week.

The insurer denied Increase personal care aide (PCA) Level II: 12 hours per day - 7 days per week - a total of 84 hours per week.  The denial is overturned.

This elderly female patient has conditions including subdural hematoma, hypothyroidism, urinary incontinence, hypertension, hyperlipidemia, and peripheral arterial disease.  She is appealing the denial of an increase in personal care aide (PCA), 12 hours per day, seven days per week, for a total of 84 hours per week.  The plan approved 35 hours per week.  Uniform assessment system (UAS) evaluation shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with bathing, lower body dressing, walking, locomotion, and toileting; extensive assistance with managing medications, personal hygiene, upper body dressing, and bed mobility; supervision with phone use; and independent with eating.  She has frequent bladder incontinence. Compared to Uniform assessment system (UAS) evaluation completed prior, there has been a decline with bed mobility. Records including clinical notes, discharge statement and provider's letter were reviewed.  These records note that the patient needs home care due to a fall that resulted in subdural hematoma.  The patient had a small bowel resection and has deconditioning, urinary incontinence, gait difficulties, and memory decline. The provider notes the patient needs assistance with activities of daily living (ADLs)/instrumental activities of daily living (IADLs), except eating.  The provider recommends 12 hours, seven days per week home care services.

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.  She was recently hospitalized with a subdural hematoma as result of a fall.  She is appealing denial of increase personal care aide (PCA) 12 hours per day, seven days per week, for a total of 84 hours per week.  The plan approved 35 hours per week.  

Uniform assessment system (UAS) evaluation shows the patient requires assistance with all activities of daily living (ADLs), except eating.  She is incontinent of bladder.  Compared to Uniform Assessment System (UAS) evaluation completed prior, there has been a decline with bed mobility. The additional hours were denied by the plan based on Uniform Assessment System (UAS) evaluations and additional hours are not provided when tasks are not being performed.  The information provided shows that this patient has significant limitations in functioning.  Her needs for assistance with activities of daily living (ADLs) as noted above cannot be met with the approved personal care aide (PCA) 35 hours per week.  The proposed PCA 84 hours per week is medically necessary.