Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal stenosis, post stroke depression (PSD), back pain, knee pain, fibromyalgia, and memory loss
Treatment: Personal Assistance Services (PAS) - 8 Hours per Day, 5 Days per Week, for a Total of 40 Hours per Week
The insurer denied the PAS - 8 hours per day, 5 days per week, for a total of 40 hours per week.
The denial is overturned. 

This female has medical conditions including spinal stenosis, post stroke depression (PSD), back pain, knee pain, fibromyalgia, and memory loss.  She is appealing denial of increase in personal care assistance (PCA) hours from 20 to 40 hours per week.  She lives with her children and grandchildren, but they are unable to assist her.  

Uniform Assessment System (UAS) evaluation performed shows modified independent cognition and functional status: maximal assistance with meal preparation and housework; extensive assistance with managing medications, stairs, shopping, and transportation; limited assistance with managing finances, bathing, lower body dressing, toilet transfer, walking, and locomotion; independent with personal hygiene, upper body dressing, toilet use, bed mobility, and eating.  She is physically active three to four hours per day.  She ambulates with a cane or walker indoors and a scooter outdoors.  She is occasionally incontinent of bowel and bladder.  Durable medical equipment (DME) includes shower chair, shower bars, scooter, cane, walker and Life Alert.  She was hospitalized after complaining of head pain and was diagnosed with a brain aneurysm.  Compared to UAS evaluation performed a year prior, there has been a deterioration in ability to perform meal preparation, housework, managing medications, toilet transfer, walking and locomotion.  

Appeal statement from New York State notes the patient needs assistance with activities of daily living (ADLs) as already accounted for in the UAS evaluation.  It states additional hours are needed due to decline in the patient's health condition.  A letter from the provider recommends increasing personal assistance service (PAS) hours due to diagnoses of knee pain and fibromyalgia that limit her range of motion and cause disability.

Yes, the proposed PAS - 8 hours per day, 5 days per week, for a total of 40 hours per week is medically necessary.

The proposed treatment is medically necessary because it is consistent with standard of care.

Personal assistance services provide hands-on assistance to individuals to include: assistance with ADLs, health maintenance activities, and routine support services.  

This patient is homebound.  This patient has multiple chronic conditions including limited mobility.  The requested PCA 40 hours per week was denied.  She has been approved for 20 PCA hours per week.  UAS evaluation performed shows the patient requires assistance with meal preparation, housework, managing medications, stairs, shopping, transportation, managing finances, bathing, lower body dressing, toilet transfer, walking, and locomotion.  Compared to UAS evaluation performed a year prior, there has been a deterioration in ability to perform meal preparation, housework, managing medications, toilet transfer, walking and locomotion.  Appeal statements recommend additional hours due to a decline in the patient's functional status.  The reported decline has been confirmed by the UAS evaluations.  Due to this deterioration, the ongoing PCA 20 hours per week is no longer adequate to meet this patient's needs for assistance with ADLs/instrumental activities of daily living (IADLs).  The proposed increase to PCA 40 hours per week is medically necessary to meet this patient's need for assistance with ADLs and personal care.