Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pain, dysphagia, gastroesophageal reflux disease (GERD)
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 56 Hours per Week
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total Amount of 56 Hours per Week
The denial is overturned.

This elderly female patient has conditions including pain, dysphagia, gastroesophageal reflux disease (GERD), gait abnormality, poor memory, myalgia, and depression. The denial of an increase in personal care aide (PCA) services for a total amount of 56 hours per week is being appealed. The health plan approved personal care aide services for 6 hours per day - 7 days per week - for a total of 42 hours per week.

Uniform Assessment System (UAS) evaluation completed 5 months ago shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, bathing, lower body dressing, walking, locomotion, and toilet transfer; extensive assistance with managing finances and medications, personal hygiene, upper body dressing, toile use, and bed mobility; and independent with eating. She has frequent bladder incontinence. Compared to Uniform Assessment System evaluation the previous year, there has been a decline with lower body dressing, toilet transfer, bathing, walking, and locomotion. A letter from the patient's child notes that her health has significantly deteriorated. The patient now has leg pain that affects her ability to get out of bed. She has difficulty walking without assistance. She lives alone. A letter from the patient's physician notes the patient has had several falls. She has difficulty walking and with activities of daily living (ADLs). She needs human supervision during most of the day. Due to memory loss, she misses her evening medications.

The proposed treatment 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. The denial of an increase in personal care aide (PCA) services for a total amount of 56 hours per week is being appealed. The health plan approved personal care aide services for 6 hours per day - 7 days per week - for a total of 42 hours per week. Uniform Assessment System (UAS) evaluation completed 5 months ago shows the patient requires assistance with all activities of daily living (ADLs), except eating. Compared to Uniform Assessment System evaluation the previous year, there has been a decline with lower body dressing, toilet transfer, bathing, walking, and locomotion. The patient has frequent bladder incontinence. The appeal statements support a decline in the patient's functioning and need for assistance with activities of daily living. The information provided supports that the patient has significant impairments. Her functioning has declined between Uniform Assessment System evaluations. The proposed increase in personal care aide (PCA) hours from 42 to 56 hours per week is appropriate for this patient's needs.