Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Age-related cognitive decline, Anxiety disorder, Atherosclerotic heart disease, Constipation, Dizziness and giddiness, Essential hypertension, Insomnia, Localized edema, Muscle weakness, Fatigue, Polyosteoarthritis, Breast cancer, and Hypercholesterolemia
Treatment: Increase Personal Care Services To 12 Hours Per Day 7 Days Per Week For A Total of 84 Hours Per Week
The insurer denied the Increase Personal Care Services To 12 Hours Per Day 7 Days Per Week For A Total of 84 Hours Per Week
The denial is overturned

The patient is a female. Her conditions include Age-related cognitive decline, Anxiety disorder, Atherosclerotic heart disease, Constipation, Dizziness and giddiness, Essential hypertension, Insomnia, Localized edema, Muscle weakness, Fatigue, Polyosteoarthritis, Breast cancer, and Hypercholesterolemia. She lives with her spouse. Her daughter directs her care. Denial of increase personal care services (PCS) to 12 hours per day 7 days per week for a total of 84 hours per week, is being appealed. The health plan approved PCS (Personal Care Services) 7 hours per day, 5 days per week for a total of 35 hours per week.

The patient's Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: maximal assistance with managing medications, phone. use; extensive assistance with bathing, personal hygiene, lower body dressing, toilet use; limited assistance with upper body dressing, and toilet transfer; and supervision with bed mobility and eating. She requires prompting with ADLs (activities of daily living). She ambulates with a walker indoors and uses a wheelchair outdoors. She has frequent bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in cognition and functional status with managing medications, bathing, personal hygiene, crossing, walking, locomotion, toileting, bed mobility, eating, and incontinence.

A letter from the patient's doctor notes the patient's cognitive and functional condition has significantly deteriorated in the past few months. She is progressively weakening and experiencing confusions. Her gait has become unstable, making her a high fall risk. A letter dated from another doctor notes the patient has declined in cognitive and physical functioning and is no longer able to function independently. Notes she needs assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation.

Yes, the requested increase in Personal Care Services to 84 hours/week is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase PCS (personal care services) to 12 hours per day 7 days per week for a total of 84 hours per week, is being appealed. The health plan approved PCS (personal care services) 7 hours per day, 5 days per week for a total of 35 hours per week.

The patient has several chronic conditions. UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living), except bed mobility and eating. Due to cognitive impairment, she requires prompting with all activities. The patient is incontinent of bowel and bladder. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in cognition and functional status with managing medications, bathing, personal hygiene, crossing, walking, locomotion, toileting, bed mobility, eating, and incontinence. Appeal letters note progressive deterioration in cognitive and physical functioning, to include gait instability resulting in a high fall risk. This patient has significant limitations that require assistance. UAS (Uniform Assessment System) evaluations show that her condition is deteriorating. Due to the deterioration and the amount of assistance needed, the approved PCS (Personal Care Services) 35 hours per week is insufficient to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase in PCS (Personal Care Services) to a total 84 per week is medically necessary.