Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neurocognitive disorder, diabetes, hypertension, stroke with unstable gait, lumbar radiculopathy, arthritis of knees, and urinary incontinence.
Treatment: Increase Personal Care Aide from 7 Days a Week 8 Hours a Day to 7 Days a Week 12 Hours a Day, Total 84 Hours per Week.
The insurer denied the increase personal care aide from 7 days a week 8 hours a day to 7 days a week 12 hours a day, total 84 hours per week.
The denial is overturned. 

This patient is a female with conditions including neurocognitive disorder, diabetes, hypertension, stroke with unstable gait, lumbar radiculopathy, arthritis of knees, and urinary incontinence.  The patient is appealing denial of personal care aide (PCA) 12 hours per day, 84 hours per week.  She has been approved for eight hours per day, 56 hours per week.  

The patient lives in an apartment.  Her daughter-in-law helps with medications.  Uniform Assessment System (UAS) evaluation performed shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with stairs, transportation, bathing, lower body dressing, and toilet use; extensive assistance with managing medications, phone use, personal hygiene, and upper body dressing; and limited assistance with walking, locomotion, bed mobility, and eating.  The patient uses pull ups that are changed by aide.  The patient is frequently incontinent of bowel and bladder.  There have been no hospitalizations in the past 90 days.  She has equipment including a personal emergency response system (PERS), cane, rollator, shower chair, and grab bar.  She is able to walk 15 to 149 feet with walker and limited help.  

A Uniform Assessment System (UAS) evaluation was performed and compared to the evaluation performed four months prior, shows decline in cognition, stairs, bathing, personal hygiene, dressing, toileting, bed mobility, and eating.  

A letter from the patient's provider states the patient's condition has become worse.  She needs increased home health aide (HHA) hours to help her with activities of daily living (ADLs), accompanying her to doctor appointments and treatment.

Yes, the proposed treatment is medically necessary.

Medically necessary services are those which are: safe, effective, generally accepted national standards of medical practice, not provided primarily for convenience of the patient or the practitioner, the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standards of medical practice.

This patient has multiple chronic conditions, including cognitive impairment and limited mobility.  The requested personal care aide (PCA) at 12 hours per day, 84 hours per week were denied.  The patient has been approved eight hours per day, 56 hours per week.  Uniform Assessment System (UAS) evaluation performed shows the patient requires assistance with all activities of daily living (ADLs)/instrumental activities of daily living (IADLs).  Compared to the evaluation performed four months prior, the patient's functional status has declined in cognition, stairs, bathing, personal hygiene, dressing, toileting, bed mobility, and eating.  She has family to help with her medications.  The patient is incontinent of bowel and bladder.  She uses pull-ups and relies on the aide to change them, which means she wears soiled pull-ups until the aid returns in the morning.  Appeal letter from the provider notes that the patient's functional status has declined.  Uniform Assessment System (UAS) evaluations show the patient's cognitive and functional status have declined over four months to where she now requires assistance with all activities of daily living (ADLs)/instrumental activities of daily living (IADLs).  Based on the patent's current functional status, the proposed increase in personal care aide (PCA) services to a 12 hours per day is medically necessary to meet this patient's needs.