Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, heart failure, hypothyroidism,
orthostatic hypotension, dizziness, back pain and
arthritis
Treatment: Increase Personal Care Aide Hours from 7 Days a Week 10 Hours a Day TO 7 Days a Week 12 Hours a Day
The insurer denied the Increase Personal Care Aide Hours from 7 Days a Week 10 Hours a Day TO 7 Days a Week 12 Hours a Day
The denial is overturned. 

This male has conditions including hypertension, heart failure, hypothyroidism, orthostatic hypotension, dizziness, back pain and arthritis.  He is appealing denial of personal care aide (PCA) services at 84 hours per week.  He has been approved for 70 hours per week.  

Uniform Assessment System (UAS) evaluation performed shows modified independent cognition and functional status: total dependence with meal preparation and housework; maximal assistance with shopping, transportation, and bathing; extensive assistance with managing finances and medications, personal hygiene, dressing, walking, and toileting; and independent with bed mobility and eating.  During evaluation, the patient refused to ambulate due to weakness and fatigue.  His family reports the patient can transfer with walker and ambulate with one person weight bearing.  He is occasionally incontinent of bladder.  Compared to Uniform Assessment System (UAS) evaluation performed four months prior, the patient's requires more assistance with bathing and medication management.  In addition, activity level has decreased from less than one hour to none.  He has equipment including a walker, wheelchair, shower bench, urinal and grab bar in his bathroom.  He has declined personal emergency response system (PERS) and physical therapy (PT) services.

Appeal letter states the patient has rapidly deteriorating mental and functional status.  It states the patient is mostly bed and wheelchair bound due to prolonged immobility and muscle atrophy in lower extremities.  Provider notes the patient has a history of repeated falls and is a high fall risk.  He had a fall three months ago.  It notes need for assistance as already noted in the Uniform Assessment System (UAS) evaluation.

Yes, the proposed treatment is medically necessary.
Medically necessary services are those which are:
-	Safe
-	Effective
-	Generally accepted national standard of medical practice
-	Not provided primarily for convenience of the patient or the practitioner
-	The least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice

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.  This patient is appealing denial of personal care aide (PCA) services at 84 hours per week.  He has been approved for 70 hours per week.  

The Uniform Assessment System (UAS) evaluation shows the patient needs assistance with all activities of daily living (ADLs) / instrumental activities of daily living (IADLs) with exception of bed mobility and eating.  Compared to the evaluation performed four months prior, the patient's physical activity level is now none and the patient requires more assistance with bathing and medication management.  The patient has equipment including a walker, wheelchair, shower bench, urinal and grab bar in his bathroom.  Appeal letter from the provider states the patient's cognitive and functional status is rapidly deteriorating and the patient is mostly bed and wheelchair bound due to immobility resulting in muscle weakness.  The Uniform Assessment System (UAS) evaluation supports this with the assessment showing no physical activity.  It is noted that the patient is able to ambulate with assistance, but does not.  This patient has poor functional status due to immobility and has refused physical therapy.  This patient is inactive and requires significant assistance with activities of daily living (ADLs) / instrumental activities of daily living (IADLs). The approved personal care services (PCS) 70 hours per week are insufficient to meet this patient's needs.  In addition to physical therapy (PT) which is appropriate to improve muscle strength and mobility, the proposed increase in personal care aide (PCA) services to a total 84 per week is medically necessary to meets this patient's need for assistance with activities of daily living (ADLs) and personal care.