Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Legally blind, tongue cancer
Treatment: Increase in Personal Care Aide Level II; 12 Hours per Day, 7 Days per Week, a Total of 168 Hours per Week
The insurer denied the Increase in Personal Care Aide Level II; 12 Hours per Day, 7 Days per Week, a Total of 168 Hours per Week
The denial is upheld

This female patient has conditions including dementia, arthritis, legally blind and tongue cancer status post partial glossectomy.  She is appealing denial of increase in personal care aide level II, 12 hours per day, seven days per week, a total of 168 hours per week.  The health plan approved 47 hours per week.  Additional hours were requested due to vision impairment, risk for falls, limited mobility, and need for more assistance with housework, toileting, walking, and safety supervision.  

Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing medications and finances, phone use, and shopping; extensive assistance with bathing, lower body dressing, walking, locomotion, and toilet transfer; limited assistance with upper body dressing and toilet use; and supervision with personal hygiene, bed mobility and eating.  She has frequent bladder incontinence.  She had a fall.  Uniform Assessment System (UAS) evaluation completed most recently shows a change in bed mobility and eating to limited supervision.  The patient had a fall due to weakness.  She is able to ambulate with a walker.  The patient lives with her son and his family who are supportive in her care.

No, the proposed Increase in Personal Care Aide Level II; 12 Hours per Day, Seven Days per Week, a Total of 168 Hours per Week 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.  Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift.

This patient is legally blind and status post glossectomy due to tongue cancer.  She is appealing denial of increase in personal care aide level II, 12 hours a day, seven days per week, a total of 168 hours per week.  The health plan approved 47 hours per week.  The patient's Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing medications and finances, phone use, and shopping; extensive assistance with bathing, lower body dressing, walking, locomotion, and toilet transfer; limited assistance with upper body dressing and toilet use; and supervision with personal hygiene, bed mobility and eating.  She has bladder incontinence.  Uniform Assessment System (UAS) evaluation completed shows a change in bed mobility and eating to limited supervision.  The patient had a fall due to weakness.  The patient lives with her son and his family who provide support.  The information provided does not support that the patient has needs that requires 24-hour, continuous care, assistance.  She does not require repositioning/turning or need for transfers and toileting throughout the day and night.  Personal care aide (PCA) is not indicated when no tasks are being performed or for supervision.  The approved personal care aide (PCA) 47 hours per week is appropriate and medically indicated to meet the patient's needs for assistance with activities of daily living (ADLs) and personal care.  The proposed increase in personal care aide (PCA) 24 hours, continuous care, is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.