Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, heart disease, memory loss. 
Treatment: Increase Personal Care Aide (PCA) Services For a Total Amount of 59.5 hours per week. 
The insurer denied the Increase Personal Care Aide (PCA) Services For a Total Amount of 59.5 hours per week. 
The denial is overturned. 

This female patient has conditions including diabetes, heart disease, hypertension, hyperlipidemia, and memory loss.  She is appealing denial of increase in personal care aide (PCA) services for a total amount of 59.5 hours per week.  The health plan approved 31.5 hours per week. 

Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation and managing medications; extensive assistance with managing finances, bathing, and toilet transfer; limited assistance with personal hygiene, dressing, walking, locomotion, toilet use, and bed mobility; and independent with eating. Comparison to Uniform Assessment System (UAS) evaluation completed previously, there has been a decline in cognition. She has frequent bladder incontinence. A letter from providers note the patient has muscle weakness and unsteady gait and requires contact guard assistance whenever ambulating. She uses a walker indoors and a wheelchair when outside. She is frequently incontinent and unable to dress and clean herself. She does not have informal support. The letter states the patient is totally dependent for ambulation, toilet use, incontinence care, transferring, bathing, medication reminders, meal preparation, housework, managing finances and medication, shopping and bed mobility. 

Yes, the proposed treatment is medically necessary. 

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 several chronic conditions. She is appealing denial of increase in personal care aide (PCA) services for a total amount of 59.5 hours per week. The health plan approved 31.5 hours per week. 

Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs), expect eating. The patient has frequent bladder incontinence. The appeal letters note the patient has an unsteady gait and requires assistance whenever ambulating. It notes that she requires assistance with cleaning and dressing due to frequent urinary incontinence. The letters note the patient is dependent with several activities of daily living (ADLs) / instrumental activities of daily living (IADLs). This patient has significant physical impairments affecting her ability to perform activities of daily living (ADLs). The approved personal care aide (PCA) 31.5 hours per week is inadequate to meet the member's needs for assistance with activities of daily living (ADLs) / instrumental activities of daily living (IADLs). The proposed increase in personal care aide (PCA) to a total 59.5 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.