Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, rheumatoid arthritis, carpal tunnel, urinary incontinence
Treatment: Personal care aide (PCA) services - ten hours per day, five days per week, for a total of 50 hours per week
The insurer denied the Personal care aide (PCA) services - ten hours per day, five days per week, for a total of 50 hours per week.
The denial is overturned.

This female has conditions including osteoarthritis, rheumatoid arthritis, carpal tunnel, edema, hypertension, gastroesophageal reflux disease (GERD), urinary incontinence, osteoporosis, asthma, and diabetes.  She lives alone in an apartment.  She is appealing denial of personal care aide (PCA) services 50 hours per week.  Hours were increased from 32.5 to 37.5 hours per week.  

Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with housework, and stairs; maximal assistance with meal preparation, shopping, transportation, bathing, personal hygiene, dressing, walking, locomotion, toileting, bed mobility and eating; and extensive assistance with managing finances and medications.  She is incontinent of bowel and bladder and uses four to five pull-ups per day.  Compared to Uniform Assessment System (UAS) evaluation completed a month prior, there has been a decline in functional status with housework, bed mobility and eating.  Durable medical equipment (DME) includes cane, glucometer, shower chair, shower grab bar, walker, wheelchair, blood pressure cuff and incontinence supplies.  

Yes, the proposed treatment is medically necessary.

The proposed treatment is medically necessary because it is consistent with standard of care.

Appeal statement recommends increased hours due to the patient's multiple chronic and deteriorating condition.  Letters from providers recommend increased hours due to debilitating medical conditions.

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 multiple chronic conditions, including arthritis and unsteady gait due to stiffness.  She is appealing denial of personal care aide (PCA) services at 50 hours per week.  Four months prior, there was a partial increase in personal care aide (PCA) hours from 32.5 to 37.5.  Uniform Assessment System (UAS) evaluation completed shows the patient needs assistance with all activities of daily living (ADLs).  Assistance required is mostly maximal to total dependence.  She has bowel and bladder incontinence and uses four to five pull-ups per day.  Compared to Uniform Assessment System (UAS) evaluation completed approximately a month prior, there has been a decline in functional status with housework, bed mobility and eating.  She has bowel and bladder incontinence.  Appeal statements are recommending increased hours due to deteriorating medical conditions affecting ability to perform activities of daily living (ADLs).  This patient has significant debility limiting her ability to perform activities of daily living (ADLs)/instrumental activities of daily living (IADLs).  The approved personal care aide (PCA) 37.5 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living (ADLs) and personal care as noted above.  The proposed increase in personal care aide (PCA) to 50 hours per week is medically necessary.