Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, osteoarthritis, CAD (coronary artery disease), HTN (hypertension), depression, IBS-D (Irritable Bowel Syndrome with Diarrhea), and urinary incontinence
Treatment: Increase in Personal Care Aide (PCA) to 84 hours per week
The insurer denied the Increase in Personal Care Aide (PCA) to 84 hours per week
The denial is overturned. 

The patient is a female. Her medical conditions include Parkinson's disease, osteoarthritis, CAD (coronary artery disease), HTN (hypertension), depression, IBS-D (Irritable Bowel Syndrome with Diarrhea), and urinary incontinence. This is an appeal of denial of increase PCA (personal care aide) from 49 hours per week to 84 hours per week. The patient's daughter is requesting additional hours, because the patient has weakness and dizziness and needs assistance with ADLs (activities of daily living).

The patient's UAS (Uniform Assessment System) evaluation completed shows the following with regard to impaired cognition and functional status: total dependence with housework, managing finances, and shopping; maximal assistance with meal preparation, managing medications, bathing, and dressing; extensive assistance with phone use, personal hygiene, walking, locomotion, toileting, and bed mobility; and limited assistance with eating. The patient has bowel and bladder incontinence. She had a recent fall and hospitalization due to cellulitis. The patient had decline over past 90 days with cognition and requires higher level of assistance. Compared to UAS (Uniform Assessment System) evaluation completed previously, the patient requires more assistance with managing finances and medications, phone use and shopping.

An appeal letter from NYLAG (New York Legal Assistance Group) notes that the patient has several chronic conditions. The letter notes progression of cognitive and functional impairments. The letter recommends additional PCA (personal care aide) hours to meet the patient's needs for assistance with ADLs (activities of daily living).

Yes, the requested Increase in Personal Care Aide (PCA) to 84 hours per week is medically necessary.
Personal Assistance 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 has multiple chronic conditions, including dementia and osteoarthritis affecting mobility and physical functioning. This is an appeal of denial of increase PCA (personal care aide) from 49 hours per week to 84 hours per week.

The patient's UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs/IADLs (activities of daily living/instrumental activities of daily living). Other than limited assistance with eating, the patient requires total dependence to extensive assistance with all other ADLs/IADLs (activities of daily living/instrumental activities of daily living). She has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, the patient requires more assistance with managing finances and medications, phone use and shopping. The patient was hospitalized after a fall. UAS (Uniform Assessment System) evaluation and appeal statements show decline in the patient's cognition and physical functioning. She does not have informal support. This patient requires a significant level of daily assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living), and there has been some decline in her status. The approved PCA (personal care aide) 49 hours per week is insufficient to meet the patient's needs. The requested increase in PCA (personal care aide) to 84 hours per week is appropriate and medically necessary to meets this patient's need for assistance with ADLs (activities of daily living) and personal care.