Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke, hypertension, uncontrolled diabetes, and peripheral artery disease. 
Treatment: Increase Personal Care Aide (PCA) Services For A Total of 60 Hours Per Week. 
The insurer denied the Increase Personal Care Aide (PCA) services for a total of 60 hours per week. 
The denial is overturned. 

The patient is a male. He has a history of stroke, hypertension, uncontrolled diabetes, and peripheral artery disease. Denial of increase personal care aide (PCA) services for a total of 60 hours per week is being appealed. The health plan approved 17.5 hours per week. 

Uniform Assessment System (UAS) evaluation performed shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping; extensive assistance with managing medications; limited assistance with bathing, personal hygiene, dressing, walking, and locomotion; supervision with bed mobility and eating; and independent with toilet use. The patient has infrequent bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with toilet transfer, walking, locomotion, and bed mobility. 

A letter from the patient's provider notes the patient's was admitted with metabolic encephalopathy. States the patient's level of functioning before admission was independent. He now requires assistance with ADLs (activities of daily living) due to cognitive issues and need for assistance. 

A letter from the patient's caseworker notes the patient cannot complete any functional tasks without assistance and is cognitively impaired. 

Yes, the requested increase in personal care aide services to 60 hours/week is medically necessary. 

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 PCA (personal care aide) services for a total of 60 hours per week is being appealed. The health plan approved 17.5 hours per week. 

The patient has several chronic conditions. He was recently hospitalized with metabolic encephalopathy. Uniform Assessment System (UAS) evaluation performed shows the patient requires assistance with all ADLs (activities of daily living), except bed mobility and eating. He has bowel and bladder incontinence. Comparison to UAS (uniform assessment system) evaluations completed previously, there is decline in toilet transfer, walking, locomotion, and bed mobility. The appeal letters note there has been a decline in the patient's level of functioning and cognitive status since admission. He is no longer able to perform ADLs (activities of daily living) without assistance. This patient has physical impairments that have progressed between Uniform Assessment System (UAS) evaluations. His functional ability declined after recent hospitalization. The approved PCA (personal care aide) 17.5 hours per week is inadequate to meet the patient's needs for assistance with ADLs (activities of daily living)/IADLs (instrumental activities of daily living). The requested increase in PCA (personal care aide) to a total 60 per week is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The requested services are medically necessary.