Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, heart failure, glaucoma
Treatment: Personal Care Aide 7 days x (times) 8 hours for a total of 56 hours/week
The insurer denied Personal Care Aide 7 days x 8 hours for a total of 56 hours/week.
The denial is overturned.

This elderly male patient has medical conditions that include osteoarthritis, coronary heart disease, heart failure, hypertension, hyperlipidemia, and glaucoma. He was diagnosed with lower gastrointestinal bleed last year. He lives by himself. The denial of personal care aide (PCA) 7 days for 8 hours for a total of 56 hours/week is being appealed. The health plan approved 7 days for 4 hours for a total 28 hours/week.

Uniform Assessment System (UAS) evaluation completed 4 months ago shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with transportation; limited assistance with managing finances and medications, bathing and dressing; supervision with walking and locomotion; and independent with personal hygiene, toileting, bed mobility, and eating. He has Durable Medical Equipment (DME) to include a cane, shower chair, and grab bar. He does not have incontinence. There have been no falls in last 90 days. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline with meal preparation, housework, managing medications, and shopping.

An appeals statement notes the patient has incontinence and needs assistance diaper changing. Also, it notes the patient does not have a cane. A letter notes the patient needs increased hours for assistance with activities of daily living (ADLs). A letter from the patient's physician notes the patient's condition is deteriorating. He has reduced mobility and is unable to walk with a walker and assistance. He requires assistance with ADLs.

The proposed treatment is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with ADLs, health maintenance activities, and routine support services. This patient has multiple chronic conditions, including a recent gastrointestinal bleed. He lives alone. The denial of PCA 7 days for 8 hours for a total of 56 hours/week is being appealed. The health plan approved 7 days for 4 hours for a total 28 hours/week. UAS evaluation completed 4 months ago shows the patient requires assistance with transportation, managing finances and medications, and bathing and dressing; and supervision with walking and locomotion. Compared to UAS evaluation completed last year, there has been a decline with meal preparation, housework, managing medications, and shopping. Appeal statements note the patient's condition is deteriorating and he needs increased hours. He has incontinence and needs assistance with diaper changes. He requires a walker and assistance for ambulation. The information provided in the appeal statements supports a significant decline in the patient's level of function. He has significant limitations that cannot be managed with the approved personal care aide 7 days for 4 hours for a total 28 hours/week. The proposed increase to 7 days for 8 hours for a total of 56 hours/week is medically necessary.