Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bladder incontinence, history of stroke, lymphedema, endometrial cancer, and poliomyelitis
Treatment: Personal Care Aide (PCA) Level 2 Live-In Per Diem: 1 day - for a total of 7 days per week
The insurer denied: Personal Care Aide (PCA) Level 2 Live-In Per Diem: 1 day - for a total of 7 days per week
The denial is overturned.

The patient is an elderly female with a history of general debility due to multiple medical issues. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 52.5 hours per week (7.5 hours per day, 7 days per week) based on Uniform Assessment System (UAS) evaluation of 9 months ago 1 day live-in per diem, 7 days a week, based on Uniform Assessment System evaluation of 5 months ago. The health plan denied the request because the patient has a supporting son who can direct her care, the patient is alert and oriented to person and place, able to make her needs known, and express an emergency plan. The health plan also denied the request because the helping aide will not help manage the patient's medical conditions as it is outside the scope of the helping aide and the patient should continue to use her wheelchair to move around. The additional hours requested are because of the patient's chronic medical conditions, and to 
help with her activities of daily living (ADLs) as she has declined in physical, functional, and cognitive ability to complete everyday tasks, and the approved 52.5 hours per week will not be adequate for her current needs. A review of the records showed that the patient has multiple chronic medical conditions including bladder incontinence, history of stroke, lymphedema, endometrial cancer, poliomyelitis since childhood, and is wheelchair-bound.
Uniform Assessment System - New York (UAS-NY) evaluation of 5 months ago showed that the patient is moderately cognitively impaired, with making decisions consistently poor or unsafe with cues needed at all times, required limited assistance with eating, extensive assistance with managing finances, personal hygiene, upper body dressing, maximal assistance for meal preparation, managing finances, phone use, shopping, bathing, lower body dressing, walking, locomotion, toilet transfer/use, bed mobility, and total dependence for housework, transportation, and stairs.
The patient lives alone in a 3-bedroom apartment on the second floor but the nephew who lives 100 minutes away, comes to check on her.

The requested increase for Personal Care Assistance through Home Health Care (Level 2) from 52.5 hours per week (7.5 hours per day, 7 days per week) to 1 day live-in per diem, 7 days 
a week, is medically necessary.

The requested increase in hours is medically necessary because the patient is moderately cognitively impaired, with making decisions consistently poor or unsafe with cues needed at all times, required limited assistance with eating, extensive assistance with managing finances, personal hygiene, upper body dressing, maximal assistance for meal preparation, managing finances, phone use, shopping, bathing, lower body dressing, walking, locomotion, toilet transfer/use, bed mobility, and total dependence for housework, transportation, and stairs.
The reasons for denial by the health plan as stated in the clinical information above do not align with the patient's disability features as stated in the Uniform Assessment System evaluation of 5 months ago. Therefore, the 1 day live-in per diem, 7 days a week, requested should be approved.