Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, osteoarthritis, COPD (chronic obstructive pulmonary disease). 
Treatment: Personal Care Aide Level II: 10 Hours/Day/ 7 day(s) per week - Total of 70 Hours Per Week. 

The insurer denied the Personal Care Aide Level II: 10 Hours/Day/ 7 day(s) per week - Total of 70 Hours Per Week. 
The denial is overturned. 

This male has conditions including dementia, cardiac disease, anemia, heart failure, chronic obstructive pulmonary disease (COPD) on home oxygen, anemia, chronic low back pain, and osteoarthritis.  He is appealing denial of personal care aide (PCA) ten hours per day, seven days per week for a total of 70 hours per week. The health approved personal care aide (PCA) eight hours per day, seven days per week for a total of 56 hours per week. 

Uniform Assessment System (UAS) evaluation completed shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, shopping, and bathing; maximal assistance with phone use, lower body dressing, walking, locomotion, and toileting; and extensive assistance with upper body dressing and bed mobility; and supervision with eating.  He has bowel and bladder incontinence.  Compared to Uniform Assessment System (UAS) evaluation completed previously, there is a decline in functional status with meal preparation, managing finances and medications, shopping, bathing, dressing personal hygiene, dressing, walking, locomotion, toileting, and eating.  A letter from the provider notes the patient has rapidly deteriorating mental and physical health and functional status.  He has limited range of motion and mobility.  He requires daily reminders with activities of daily living (ADLs).  A letter from another provider notes the patient has multiple medical conditions and several near-syncope episodes.  He requires assistance with all activities of daily living (ADLs). A letter from a provider notes the patient requires supervision around-the-clock to provide safe and clean environment, optimal nutrition and hydration, prevent falls and injuries.  His falls mostly occur at night time when he stays alone.  He has severe memory loss, confusion, disorientation, and visual hallucinations.  He does not sleep at night and wanders around.  

Yes, the proposed treatment 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.  The patient has several chronic conditions including dementia.  He is appealing denial of personal care aide (PCA) ten hours per day, seven days per week for a total of 70 hours per week.  The health approved personal care aide (PCA) eight hours per day, seven days per week for a total of 56 hours per week.  Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs), except supervision with eating.  He has bowel and bladder incontinence.  Comparison to Uniform Assessment System evaluation completed previously, there is decline in all areas of functioning.  Appeal letters indicate that the patient has deterioration of mental and physical functioning, which is supported by the Uniform Assessment System (UAS) evaluations. 

This patient has significant cognitive and physical impairments that have progressed between Uniform Assessment System evaluations.  Due to the deterioration and the patient's functional status, the approved personal care aide (PCA) 56 hours per week is inadequate to meet the member's needs for assistance with activities of daily living and personal care.  The proposed increase in personal care aide to 70 hours per week is medically necessary.