Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension, chronic kidney disease, peripheral vascular disease, and osteoarthritis, and osteoporosis.
Treatment: Increase Personal Care (PCA) Services for a Total of 168 Hours per Week, split shift.
The insurer denied the Increase Personal Care (PCA) Services for a Total of 168 Hours per Week, split shift.

The denial is overturned

The patient is a female. Her conditions include hypertension, chronic kidney disease, peripheral vascular disease, and osteoarthritis, and osteoporosis. She lives alone. Denial of increase personal care (PCA) services for a total of 168 hours per week, split shift, is being appealed. The plan approved 84 hours per week.

Uniform Assessment System (UAS) evaluation performed shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing medications, shopping, bathing, personal hygiene, dressing, toilet use, and bed mobility; extensive assistance with managing finances; and limited assistance with eating. The patient is bedbound. She has bowel and bladder incontinence. Comparison of UAS (Uniform Assessment System) evaluation most recently to the previous assessment shows decline in functioning with personal hygiene, toilet transfer, walking, locomotion, and eating.

Appeal statements note the patient has become more disabled since hospitalizations over the past winter. She is bedbound. She has a stage 2 ulcer. She is unable to handle any ADLs (activities of daily living). She requires a bedpan every two hours overnight and needs to be turned/repositioned every 2 hours. Nighttime logs show frequent awakenings for bed pan and turning.

Yes, the requested increase in personal care aide services to 168 hours/week, split shift, is medically necessary.
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. Denial of increase personal care (PCA) services for a total of 168 hours per week, split shift, is being appealed. The plan approved 84 hours per week. The request was denied based on the UAS (Uniform Assessment System) evaluations, noting the time allotted can meet the patient's needs for assistance.

The patient has several chronic conditions, including recent hospitalizations. Uniform Assessment System (UAS) evaluation shows the patient requires assistance with all ADLs (activities of daily living). She has bowel and bladder incontinence. Comparison of UAS (Uniform Assessment System) evaluations shows decline in functioning with personal hygiene, toilet transfer, walking, locomotion, and eating. Appeal statements note the patient's functional status has declined. She is bedbound. In addition to assistance with all ADLs (activities of daily living), she needs to turning/repositioning every 2 hours and frequent assistance with toileting. Based on the frequency of needs, the approved PCA (personal care aide) 84 hours per week is inadequate to meet the patient's needs for assistance with ADLs (activities of daily living)/IADLs (instrumental activities of daily living). The requested increase PCA (personal care aide) for a total of 168 hours per week, split shift, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The requested personal care aide 168 hours/week, split shift, is medically necessary.