Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypertension, heart failure, heart disease, prostatic hyperplasia, and post-COVID condition
Treatment: Increase Personal Care Aide Level II Basic - 15 Minutes from 56 Hours Per Week To 84 Hours Per Week
The insurer denied the increase in personal care aide level II basic -15 minutes from 56 hours per week to 84 hours per week.
The denial is overturned.

The patient is a male. His conditions include dementia, hypertension, heart failure, heart disease, prostatic hyperplasia, and post-COVID (Coronavirus 2019) condition. Denial of increase in personal care aide (PCA) from 56 hours per week to 84 hours per week is being appealed.

Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with housework, bathing, and locomotion; maximal assistance with meal preparation, lower body dressing, and toileting; extensive assistance with personal hygiene, personal hygiene, and upper body dressing; and; limited assistance with managing finances and medications, phone use, bed mobility and eating. The patient requires a wheelchair and scooter for locomotion. He has occasional bowel incontinence.

A statement notes the patient's condition has worsened since his assessment. He was hospitalized for COVID with residual shortness of breath and bladder catheter for urinary retention.

A letter from the patient's provider notes the patient has developed urinary retention, hyponatremia and unsteady gait after 2 recent hospitalizations in the past month. Since COVID infection, he has exertional shortness of breath, weakness, and memory loss. He has fallen 4 times in the last month. He needs cuing and reminders for all activities. He needs every-two-hours assistance with management of his Foley as well as assistance with other ADLs (activities of daily living). He lives alone. His daughter is able to provide informal nighttime assistance.

Yes, the requested increase in PCA level II basic -15 minutes from 56 hours per week to 84 hours per week is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

Personal Care Services provide hands-on assistance to individuals to include: assistance with ADLs, health maintenance activities, and routine support services. Denial of increase in PCA from 56 hours per week to 84 hours per week is being appealed.

The patient has several chronic conditions including post COVID syndrome. He lives alone. UAS evaluation completed shows the patient requires assistance with all ADLs. He has bowel incontinence. Appeal statements note that the patient's condition has deteriorated since hospitalization due to COVID. Post COVID, the patient has exertional shortness of breath, weakness, and memory loss. He has an indwelling Foley catheter and needs frequent assistance with maintenance. This patient has significant cognitive and physical impairments that have progressed since hospitalization. The approved PCA 56 hours per week is inadequate to meet the patient's needs for assistance with ADLs/IADLs (instrumental activities of daily living). The proposed increase in PCA to a total 84 per week is medically necessary.