Appeal type: Medical necessity
Decision: Upheld

Diagnosis: William's Syndrome
Treatment: Increase Personal Care Assistance Services To 84 Hours Per Week
The insurer denied: Increase Personal Care Assistance Services To 84 Hours Per Week
The denial is upheld.

The patient is an adult male. His medical conditions include William's Syndrome, intellectual disability, anemia, muscle weakness, and end stage liver disease. He lives with his mother and sister. Denial of increase personal care assistance services to 84 hours per week is being appealed. The health plan approved 40 hour per week. The additional hours are being requested, because the patient does not understand mentally what he is doing: he does not know how to turn off gas or water; and needs assistance with ADLs (activities of daily living). The patient's Uniform Assessment System (UAS) evaluation performed last month shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, and transportation; extensive assistance with bathing, lower body dressing, and eating; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toilet use; independent with bed mobility; and supervision with toilet transfer. The patient has frequent bladder incontinence. His mother provides informal support. She changes his pull ups one to two times per day as needed. A letter from the patient's provider reports that the patient's condition has been gradually deteriorating. The patient became incontinent of urine at night. He is preparing for a liver transplant. He is unable to perform routine daily activities and needs constant help and support. A letter from another provider reports chronic hepatitis B and cirrhosis.

The requested health service is not 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. Denial of increase personal care assistance (PCA) services to 84 hours per week is being appealed. The health plan approved 40 hour per week. This patient has multiple medical conditions, including intellectual disability. Uniform Assessment System (UAS) evaluation completed last month shows the patient needs extensive assistance with bathing, lower body dressing, and eating, and limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toilet use. He has bladder incontinence. His mother provides informal support. Appeal statements request additional care because his condition has been gradually deteriorating and he needs constant help and support. The appeal statements indicate additional hours of services are needed due to the patient's mental impairment and inability to be left alone as he is reported to not understand using gas and water. The UAS (Uniform Assessment System) evaluation does not support the need for constant support with ADLs (activities of daily living). PCA (personal care assistance) is not indicated for when no tasks are being performed or for supervision. The requested PCA (personal care assistance) 84 hours per week is not indicated to meet this patient's needs for assistance with ADLs (activities of daily living). The approved PCS (personal care service) 40 hours per week is appropriate.