Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis, heart disease, gait issues, weakness,
and history of falls
Treatment: Increase Personal Care Aide Services from 40 Hours per Week to 84 Hours per Week
The insurer denied the Increase Personal Care Aide Services from 40 Hours per Week to 84 Hours per Week
The denial is overturned

This female patient has conditions including arthritis, heart disease, gait issues, weakness, and history of falls.  She is appealing denial of increase in personal care aide services (PCA) from 40 hours per week to 84 hours per week.  The health plan has approved an increase to 49 hours per week.  The patient's daughter notes that due to aging and severe arthritis, the patient's movements have been limited and the patient is not able to support her weight.  She is dependent for all activities of daily living (ADLs).

Uniform Assessment System (UAS) evaluation performed showed modified independent cognition and  functional status: maximal assistance with meal preparation, housework, bathing, lower body dressing, and toileting; extensive assistance with personal hygiene, upper body dressing, walking, and locomotion; limited assistance with bed mobility, and independent with eating.   She has frequent bladder incontinence and occasional bowel incontinence.  Compared to Uniform Assessment System (UAS) evaluation completed previously, there has been a decline in functional status with bathing, personal hygiene, lower body dressing, and toileting.

 A letter the provider notes the patient has multiple conditions.  She is wheelchair and home bound.  She cannot ambulate and needs assistance to get up from a sitting position. The letter states that the patient is totally dependent on home care.

Yes, the proposed treatment, an Increase in Personal Care Aide Services from 40 Hours per Week to 84 Hours per Week 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.  This patient has several chronic conditions.  She is appealing denial of an increase in personal care services from 40 hours per week to 84 hours per week.  The health plan has approved an increase to 49 hours per week. 

Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs), except eating.  She has bowel and bladder incontinence.  Compared to Uniform Assessment System (UAS) evaluation completed previously, there has been a decline in functional status with bathing, personal hygiene, lower body dressing, and toileting.  The appeal letter from her doctor notes the patient is wheelchair bound.  This patient has significant impairments and mobility limitations that have progressed between Uniform Assessment System (UAS) evaluations.  The approved personal care aide (PCA) 49 hours per week is inadequate to meet the patient's needs for assistance with activities of daily living (ADLs)/instrumental activities of daily living (IADLs).  The proposed increase in personal care services (PCS) to a total 84 per week is medically necessary.