Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Primary lateral sclerosis, osteoarthritis of the hip, hypertension, anemia and numbness/tingling of the foot
Treatment: Increase Personal Care Aide (PCA) Services for a Total of 21 Hours per Week
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total of 21 Hours per Week.
The denial is overturned.

This elderly female has primary lateral sclerosis, osteoarthritis of the hip, hypertension, anemia and numbness/tingling of her foot. She is status post open reduction of left pelvic acetabulum. Denial of increase personal care aide (PCA) services for a total of 21 hours per week is being appealed. The health plan approved 11 hours per week. Uniform Assessment System evaluation completed 2 months ago, shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, bathing, and lower body dressing; extensive assistance with walking, locomotion, toileting, and bed mobility; limited assistance with upper body dressing; supervision with managing medications; and independent with phone use, personal hygiene, and eating. She has frequent bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed 8 months ago, there has been a decline with bed mobility.  A statement from the member's daughter notes the member is just learning to use a wheelchair. She cannot get herself out of bed into a wheelchair. She needs assistance with cooking and bathing. She lives alone. A letter from her provider notes the member is completely dependent with motorized scooter for mobility. She is status post a third degree burn due to inability to lift cookware. She needs assistance with ADLs (activities of daily living) and is at high risk of injury. A letter from another provider notes the member has worsened muscle weakness. She cannot ambulate independently or perform ADLs (activities of daily living) due to lack of dexterity and inability to ambulate. She has fallen many times. 

The proposed treatment is medically necessary. 

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 primary lateral sclerosis and recent hip surgery. The denial of an increase in personal care aide (PCA) services for a total of 21 hours per week is being appealed. The health plan denied the increase based on Uniform Assessment System (UAS) evaluation completed 2 months ago. The health plan approved 11 hours per week. Uniform Assessment System evaluation completed 2 months ago, shows the patient requires assistance with all activities of daily living, except managing medications, phone use, personal hygiene, and eating. Compared to Uniform Assessment System evaluation completed 8 months ago, there has been a decline with bed mobility. Appeal statements note there has been a progressive decline in the patient's physical functioning. The patient lives alone. She is unable to transfer and ambulate without assistance. She has a history of falls. The information provided shows that this patient has significant limitations in functioning. The approved PCA (personal care aide) 11 hours per week is insufficient to meet this member's needs for assistance with ADLs (activities of daily living). The proposed increase to 21 hours per week is medically necessary.