Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, spinal stenosis, osteoporosis.
Treatment: Increase Personal Care Aide (PCA) - Level II: Eight Hours per Day, Seven Days per Week - Total of 56 Hours per Week.
The insurer denied the Increase Personal Care Aide (PCA) - Level II: Eight Hours per Day, Seven Days per Week - Total of 56 Hours per Week.
The denial is overturned.

This female has conditions including osteoarthritis, spinal stenosis, osteoporosis, hypertension, edema, and hypercholesterolemia.  She has impaired gait and balance due to arthritis.  The patient's daughter is appealing denial of personal care aide (PCA) 56 hours per week.  The patient's daughter states that the patient has lower extremity edema, chronic pain and needs more assistance with dinner and nighttime routine for bed.  She was approved for 25 hours per week.  

Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with housework and managing finances; maximal assistance with meal preparation, managing medications, and shopping; extensive assistance with bathing, personal hygiene, dressing, walking, locomotion, and toilet transfer; limited assistance with phone use and toilet use; and independent with bed mobility and eating.  Compared to Uniform Assessment System (UAS) evaluation completed previously, there is a decline from the need for limited assistance to extensive assistance with upper body dressing, personal hygiene, toilet transfer, walking, and locomotion.  She ambulates with a rollator.  She is infrequently incontinent of bladder.

Yes, the proposed Increase in Personal Care Aide (PCA) - Level II: Eight Hours per Day, Seven Days per Week - Total of 56 Hours per Week is medically necessary.
The proposed treatment is consistent with standard of care.

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 has multiple chronic conditions. She has limited mobility.  The patient's daughter is appealing the denial of personal care services (PCS) 56 hours per week.  The patient has been approved for personal care services (PCS) 25 hours per week.  Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs) / instrumental activities of daily living (IADLs), except bed mobility and eating.  Compared to Uniform Assessment System (UAS) evaluation completed previously, there is a decline from the need for limited assistance to extensive assistance with upper body dressing, personal hygiene, toilet transfer, walking, and locomotion.  Uniform Assessment System (UAS) evaluations show that there has been a significant decline in the patient's functional status where she now requires more assistance activities of daily living (ADLs).  Based on the decline in the patient's functional status, the approved personal care services (PCS) 25 hours per week is insufficient to meet the patient's needs for assistance with activities of daily living (ADLs) / instrumental activities of daily living (IADLs).  The proposed personal care services (PCS) 56 hours per week are appropriate and medically necessary.