Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post stroke, fall
Treatment: Increase Personal Care Aide (PCA) Services for A Total of 168 Hours Per Week (split shift)
The insurer denied Increase Personal Care Aide (PCA) Services for A Total of 168 Hours Per Week (split shift).
The denial is overturned.

The patient is an elderly female with a history of general debility status post CVA (cerebrovascular accident) and falls along with dementia. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 52.5 hours per week (7.5 hours per day, 7 days per week) based on UAS (Uniform Assessment System) evaluation of last year to 168 hours per week (24 hours per day, 7 days per week) based on UAS (Uniform Assessment System) evaluation of 5 months ago, with significant change in status for both dates. The health plan denied coverage of the request, noting that the patient has a supportive daughter who can direct her care, and that the patient is alert and oriented to person and place, can make her needs known, can express an emergency plan. They further note that the patient's ADLs (activities of daily living) needs have remained the same in terms of help for upper/lower body dressing, personal hygiene, bed mobility, walking, locomotion, bathing, toilet transfer, toilet use, eating, meal preparation, medication management, and housework. The additional hours requested are because of the patient's chronic medical conditions, with a history of CVA (cerebrovascular accident) and frequent falls, and to help with her Activities of Daily Living (ADLs). It is noted that she requires extensive assistance with most of her ADLs (activities of daily living), and she is unable to care for herself especially at nighttime, when she needs turning/positioning to prevent bed sores, toileting and feeding. It is also noted that she fell at night. A review of the records showed that the patient has multiple chronic medical conditions, including dementia, CVA (cerebrovascular accident), depression, hyperlipidemia, anemia, hypertension, generalized osteoarthritis, and urinary incontinence. The patient's UAS (Uniform Assessment System) evaluation of 5 months ago showed that she was minimally cognitively impaired with supervision required at certain times, required limited assistance with phone use, eating, extensive assistance with personal hygiene, upper body dressing, toilet use, bed mobility, maximal assistance for meal preparation, managing medications, stairs, shopping, transportation, bathing, lower body dressing, walking, locomotion, toilet transfer, and totally dependent for housework, and managing finances. The patient lives alone in a two-bedroom private house, and her daughter is supportive.

The requested Increase Personal Care Aide (PCA) Services for A Total of 168 Hours Per Week (split shift) is medically necessary.

Based on the most recent UAS (Uniform Assessment System) evaluation of 5 months ago, the patient has a significant change in status for the worse when comparing both assessment dates. 
She was minimally cognitively impaired with supervision required at certain times, required limited assistance with phone use, eating, extensive assistance with personal hygiene, upper body dressing, toilet use, bed mobility, maximal assistance for meal preparation, managing medications, stairs, shopping, transportation, bathing, lower body dressing, walking, locomotion, toilet transfer, and totally dependent for housework, and managing finances. The reason cited by the health plan in denying the request, as noted in the clinical information above, does not align with the patient's disability features as noted in the UAS (Uniform Assessment System) evaluation of 5 months ago, as noted above. Therefore, based on the UAS (Uniform Assessment System) evaluation of 5 months ago, the requested increase to 168 hours per week (24 hours per day, 7 days per week) is medically necessary.