Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Interstitial lung disease and visual impairment
Treatment: Increase PCA (Personal Care Assistance) Services From 31 Hours Per Week To 7 Days Per Week, 12 Hours Per Day for a Total Amount 84 Hours Per Week
The insurer denied: Increase PCA (Personal Care Assistance) Services From 31 Hours Per Week To 7 Days Per Week, 12 Hours Per Day for a Total Amount 84 Hours Per Week
The denial is overturned.

The patient is an elderly male with history of general debility, declining functional status and poor endurance due to interstitial lung disease. He is also visually impaired. The request is for Personal Care Assistance through Home Health care (Level 2) to be increased from 31 hours per week based on UAS (Uniform Assessment System) evaluation of last year to 84 hours per week (12 hours per day, 7 days per week) based on UAS (Uniform Assessment System) of last month. The health plan denied coverage of the request, because the patient shows mild decline in ability to perform ADLs (activities of daily living) and that the approved hours of PCA (personal care assistance) are adequate to meet his daily care needs. The additional hours are requested because of the patient 's chronic medical conditions, and to help with his Activities of Daily Living (ADLs), as he is legally blind and requires extensive assistance for transportation, bathing, lower body dressing, walking, toilet transfer, toilet use, locomotion, bed mobility, requires maximum assistance for meal preparation, shopping, etc. A review of the records showed that patient has multiple chronic medical conditions including Covid, pneumonia, Interstitial lung disease, Diabetes Mellitus, Hypertension, Diabetic neuropathy, Diabetic retinopathy, Glaucoma, and legally blind, etc. The patient's UAS (Uniform Assessment System) evaluation of last month showed that the patient required modified indolence for making decisions, requires extensive assistance for transportation, bathing, lower body dressing, walking, toilet transfer, toilet use, locomotion, bed mobility, requires maximum assistance for meal preparation, shopping, and requires limited assistance for managing finances, personal hygiene, upper body dressing, eating, etc. The patient is legally blind, and he lives alone in an elevator-assisted apartment building and has a history of memory lapses.

The Increase PCA (Personal Care Assistance) Services From 31 Hours Per Week To 7 Days Per Week, 12 Hours Per Day for a Total Amount 84 Hours Per Week is medically necessary.

Based on the most recent UAS (Uniform Assessment System) of last month, the patient is legally blind, lives alone and requires extensive assistance for transportation, bathing, lower body dressing, walking, toilet transfer, toilet use, locomotion, bed mobility, requires maximum assistance for meal preparation, shopping, etc. The reason for denial by the health plan does not align with the patient's disability features as stated in the UAS (Uniform Assessment System) evaluation of last month as stated above. Therefore, the 84 hours per week (12 hours per day, 7 days per week), based on UAS (Uniform Assessment System) evaluation of last month is medically necessary.