Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Excision of squamous cell carcinoma from heel, osteoarthritis, hypertension, thrombocytosis, and hyperlipidemia.
Treatment: Increase Personal Care Aide Level II Basic to 8 Hours Per Day 7 Days Per Week for a Total of 56 Hours Per Week.
The insurer denied the Increase Personal Care Aide Level II Basic to 8 Hours Per Day 7 Days Per Week for a Total of 56 Hours Per Week.
The denial is overturned.

The patient is a female. Her conditions include excision of squamous cell carcinoma from heel, osteoarthritis, hypertension, thrombocytosis, and hyperlipidemia. She lives alone. Denial of increase personal care aide (PCA) to 8 hours per day, 7 days per week for a total of 56 hours per week, is being appealed. The health plan approved PCA (personal care aide) 32 hours per week.

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

An appeal letter notes that the patient's mobility was significantly impacted by the surgery. She requires additional hours for assistance with ADLs (activities of daily living). She now requires extensive assistance with walking and locomotion. She does not have informal support.

A letter from the patient's provider notes the patient needs much support since heel surgery due to impact on mobility.

Yes, the Increase Personal Care Aide Level II Basic to 8 Hours Per Day 7 Days Per Week for a Total of 56 Hours 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.
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 personal care aide (PCA) to 8 hours per day, 7 days per week for a total of 56 hours per week, is being appealed. The health plan approved PCA (personal care aide) 32 hours per week.

The patient has several chronic conditions and recently underwent heel surgery. Uniform Assessment System (UAS) evaluation completed shows she needs assistance with all ADLs (activities of daily living). Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with housework, managing medication, bathing, personal hygiene, dressing, walking, locomotion, toilet transfer, bed mobility and eating. Appeal statements note the patient's mobility has deteriorated since surgery requiring more support. This patient has significant postoperative physical impairments that have progressed between UAS (Uniform Assessment System) evaluations. Based on her level of functioning, the approved PCA (Personal Care Aide) 32 hours per week is inadequate to meet the patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living). The proposed increase in PCA (personal care aide) to 8 hours per day, 7 days per week for a total of 56 hours per week is medically necessary.