Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Legal blindness, osteoarthritis, diabetes, hypertension, cognitive impairment, schizophrenia, personality disorder, and unsteady gait. 
Treatment: Increase Personal Care Aide (PCA) Service Level 2:  5 Hours Per Day, 7 Day(s) Per Week For A Total Of 35 Hours A Week. 

The insurer denied the Increase Personal Care Aide (PCA) Service Level 2:  5 Hours Per Day, 7 Day(s) Per Week For A Total Of 35 Hours A Week. 
The denial is overturned. 

The patient is a male. He has conditions including legal blindness, osteoarthritis, diabetes, hypertension, cognitive impairment, schizophrenia, personality disorder, and unsteady gait.  He lives alone.  He is appealing denial of PCA (personal care aide) 35 hours per week.  He has been approved for PCA (personal care aide) 12 hours per week.

The patient's UAS (Uniform Assessment System) evaluation completed shows minimally impaired cognition and functional status: maximal assistance with housework; extensive assistance with meal preparation, managing medications, shopping, and transportation; limited assistance with stairs; supervision with bathing, personal hygiene, dressing, walking, locomotion, and toilet transfer; and independent with managing finances, phone use, toilet use, bed mobility and eating. He has impaired mobility.  Compared to UAS (Uniform Assessment System) evaluation completed approximately three months prior, there has been a decline in ability to perform housework, bathing, personal hygiene, dressing, walking, locomotion, and toilet transfer.  He is continent. 

An appeal letter from Social Worker notes the patient has difficulty maintaining himself at home.  He cannot perform ADLs (activities of daily living) when he is on his own. The letter notes the patient is unable to travel on his own.  It states the patient may need someone to accompany him to appointments for weekly group clinics. 

An appeal letter from the provider states the patient has a worsening neurocognitive disorder.  He has limited mobility and relies on a walker.  He has urinary incontinence due to make it to the bathroom overnight.  It states hours with home health aide are utilized by different doctors' appointments. 

An appeal letter from the Case Manager states the patient is legally blind and uses a walker.  It states the patient is alone for several days per week. 

Yes, the personal care aide 35 hours per week is medically necessary. 
The requested service is consistent with generally accepted standards of medical practice. 

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.  This patient has multiple chronic conditions including neurocognitive impairment, legally blind, and mobility impairment requiring a walker.  He is appealing denial of PCA (personal care aide) 35 hours per week.  He has been approved for PCA (personal care aide) 12 hours per week. 

UAS (Uniform Assessment System) evaluation completed shows the patient needs assistance with housework meal preparation, managing medications, shopping, transportation, and stairs.  Compared to UAS (Uniform Assessment System) evaluation completed three months prior, there has been a decline in ability to perform housework, bathing, personal hygiene, dressing, walking, locomotion, and toilet transfer. Appeal letters indicate the patient has progressive neurocognitive impairment and needs assistance with ADLs (activities of daily living) and travel.  The patient attends several doctor's appointments and needs aid to accompany him due to blindness and mobility impairment.  Most of the home health aide hours are utilized for doctor's appointments. 

Records provided support the requested increase in PCA (personal care aide) hours:  progressive neurocognitive impairment; decline in functional status between UAS (Uniform Assessment System) evaluations; and need for assistance with ADLs (activities of daily living) and travel to doctors' appointments due to blindness and limited mobility.  The currently approved PCA (personal care aide) 12 hours per week are insufficient to meet this patient's needs for assistance with ADLs (activities of daily living) and personal care as noted above.  The requested PCA (personal care aide) 35 hours per week is medically necessary for this patient.