Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, osteoporosis, chronic kidney disease, diabetes and strokes
Treatment: Increase Personal Care Aide (PCA) Hours From 63 Hours A Week To 24 Hours A Day x 7 Days Live-In
The insurer denied the Increase Personal Care Aide (PCA) Hours From 63 Hours A Week To 24 Hours A Day x 7 Days Live-In
The denial is overturned.

The patient is female. Her conditions include dementia, osteoporosis, chronic kidney disease, diabetes and strokes. She lives alone. Denial of increase Personal Care Aide (PCA) hours from 63 hours a week to 24 hours a day x 7 days, live-in, is being appealed.

UAS (Uniform Assessment System) evaluation completed shows moderately impaired cognition and functional status: total dependence with housework, and managing finances; maximal assistance with meal preparation, managing medications, shopping, bathing, lower body dressing, and toilet use; and extensive assistance with personal hygiene, upper body dressing, walking, locomotion, bed mobility, and eating. She has frequent bowel and bladder incontinence.

An appeal statement notes the patient has multiple chronic medical conditions. Notes the patient has a history of falling during the night due to weakness and unsteady gait. She had a fall one month prior to assessment. Notes the patient has poor safety awareness due to dementia.

A letter from the patient's child notes the patient's health has declined since hospital discharge. States the patient is wheelchair bound. Notes the patient falls when trying to get up at night. States she is not requesting live-in services, but is requesting supervision at night. Notes the patient needs assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation. A nighttime log shows nighttime aid providing assistance with meals, medications, transferring, and toileting approximately every 1-3 hours.

A letter from the patient's provider states the patient is dependent with all ADLs (activities of daily living) and has frequent nighttime needs, including assistance with incontinence. She requires cueing and prompting due to dementia.

A statement from the patient's physical therapy notes the patient has poor safety awareness and neuromuscular control. She is unsafe to ambulate alone and is a high fall risk.

A letter from the patient's social worker notes the patient has deteriorating medical and mental status and it is a concern for her to be home alone.

Yes, the Increase Personal Care Aide (PCA) Hours From 63 Hours A Week To 24 Hours A Day x 7 Days Live-In, it medically necessary.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase Personal Care Aide (PCA) hours from 63 hours a week to 24 hours a day x 7 days, live-in, is being appealed.

The patient has several chronic conditions including dementia and recurrent falls. She is status post hospitalization due to a fall. UAS (Uniform Assessment System) evaluation completed shows she requires extensive assistance to total dependence with all ADLs (activities of daily living). She has frequent bowel and bladder incontinence. Appeal letters state there has been a decline in her cognitive and medical functioning. These statements in addition to the nighttime log show that the patient requires frequent nighttime assistance with ADLs (activities of daily living), including transferring and toileting. The patient's functioning and nighttime needs show that the currently approved PCA (personal care aide) 63 hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase in PCA to 24 hours a day x 7 days, live-in, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.