Appeal type: Medical necessity
Decision: Overturned

Diagnosis: multiple sclerosis (MS), transverse myelitis, and recurrent urinary tract infections.
Treatment: Increase Personal Care Aide (PCA) Services For A Live-in Per Diem 24 Hours Per Day.
The insurer denied the Increase Personal Care Aide (PCA) Services For A Live-in Per Diem 24 Hours Per Day.
The denial is overturned.

The patient is a female. Her medical conditions include multiple sclerosis (MS), transverse myelitis, and recurrent urinary tract infections. She lives with a housemate that is her caregiver. Her son is supportive. Denial of increase personal care aide (PCA) services for a live-in, 24 hours per day, is being appealed. The plan approved PCA (personal care aide) services for 8 hours/day, total of 56 hours per week.

The patient's son appealed noting the patient needs assistance with personal care needs, repositioning and toileting. Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with housework, transportation, bathing, lower body dressing, walking, locomotion, toileting, and bed mobility; and maximal assistance with managing finances and medications, meal preparation, shopping, personal hygiene, upper body dressing, and eating. She has frequent bladder incontinence and infrequent bowel incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with toilet transfer, eating and bed mobility. The patient has a Hoyer lift, wheelchair and incontinent supplies.

A letter notes the patient has progressive MS (multiple sclerosis) and is wheelchair bound. She requires help with movement and transfers. Recommends 24 hour aide due to limited range of motion and strength and risk for falls and skin breakdown. A letter the patient's transverse myelitis results in her being bed and wheelchair bound. States she is a risk for skin breakdown and falls. Recommend increase in PCA (personal care aide) hours for transfers, and prevention of falls and skin breakdown. A letter notes the patient has progressive disease and is unable to fully care for herself. She is bed and wheelchair bound and requires help with all movements and transfers. She requires assistance with shifting and turning. Recommend increase in PCA (personal care aide) hours.

An overnight log shows the patient needs assistance with toileting/turning every 4-5 hours. An appeal statement notes the patient's medical condition and being bed and wheelchair bound. States she is a fall risk and needs assistance during overnight hours as per overnight logs.

The requested increase in personal care aide to 24 hours/day, live-in, is 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 (personal care aide)) services for a live-in, 24 hours per day, is being appealed. The plan approved PCA (personal care aide) services for 8 hours/day, total of 56 hours per week.

The patient is bed and wheelchair bound due to MS (multiple sclerosis) and transverse myelitis. UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with toilet transfer, eating and bed mobility. She has bowel and bladder incontinence. A Hoyer lift is used for transfer. Appeal statements show the patient's condition is progressive and she is at risk for falls and skin breakdown. Overnight log shows the patient needs assistance with toileting/turning ever 4-5 hours. This patient has significant physical impairments that have progressed between UAS (Uniform Assessment System) evaluations. She has marked limitations with the ability to perform ADLs (activities of daily living) and personal care during day and night. She has demonstrated the need for assistance with transfers and toileting overnight. The approved PCA (personal care aide) 56 hours per week is inadequate to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase in PCA (personal care aide) live-in, 24 hours per day is medically necessary and appropriate to meets this patient's needs.

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.