Appeal type: Medical necessity
Decision: Overturned

Diagnosis: stroke with result right-side weakness and dysarthria, ischemic
cardiomyopathy, CHF (congestive heart failure), and chronic kidney disease

Treatment: Increase Personal Care Aide (PCA) Services For A Total of 48 Hours Per Week
The insurer denied the Increase Personal Care Aide (PCA) Services For A Total of 48 Hours Per Week

The denial is overturned.

The patient is a female. Her conditions include stroke with result right-side
weakness and dysarthria, ischemic cardiomyopathy, CHF (congestive heart failure),
and chronic kidney disease. She lives with her husband. Denial of increase
Personal Care Aide (PCA) Services for a total of 48 hours per week is being
appealed. She has been approved for 30 hours per week. The patient's spouse is
requesting additional hours due to increased urinary incontinence and weakness.

The husband is growing too tired to assist. The patient's daughter is supportive. The
patient's DME (durable medical equipment) includes Rollator, Cane (single prong),
Shower grab bar, Shower chair, Wheelchair, Hospital Bed, Portable Oxygen
Concentrator, and Bedside Commode. UAS (Uniform Assessment System)
evaluation completed shows minimally impaired cognition and functional status:
total dependence with housework and locomotion; maximal assistance with meal
preparation, managing finances and medications, and shopping; extensive
assistance with phone use, bathing, lower body dressing, toileting and bed mobility;
limited assistance with upper body dressing; and independent with personal
hygiene and eating. She has occasional bladder incontinence. Compared to UAS
(Uniform Assessment System) evaluation completed previously, there has been a
decline in locomotion from extensive assistance to total assistance. Progress noted
notes the patient is mostly wheelchair bound, incontinent of urine, and able to walk
with walker with assist.

A letter notes the patient has limited mobility and requires assistance due to poor
coordination, lack of energy, inability to speak in full sentences, and shortness of
breath. Notes patient requires assistance with ADLs (activities of daily living) as
already accounted for in the UAS (Uniform Assessment System) evaluation. Notes
the patient's husband is unable to supplement the current PCA (personal care aide)
30 hours per week.

Yes, the requested increase in personal care aide to 48 hours/week 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. Denial of increase Personal Care Aide (PCA) Services for
a total of 48 hours per week is being appealed. She has been approved for 30
hours per week.

This patient has multiple medical conditions including a stroke with hemiplegia and
dysarthria. UAS (Uniform Assessment System) evaluation completed shows the
patient requires assistance with all ADLs (activities of daily living) except personal
hygiene and eating. Compared to UAS (Uniform Assessment System) evaluation
completed previously, there has been a decline in locomotion from extensive
assistance to total assistance. Otherwise, there has been no change in her
functional status. Appeal statements note the patient's locomotion has deteriorated,
and her husband is no longer able to supplement the approved PCA (personal care
aide) services. The patient requires assistance with most ADLs (activities of daily
living). There has been a significant decline in her locomotion, which results in need
for more support. The approved PCA (personal care aide) 30 hours per week are
insufficient to meet the patient's needs for assistance with ADLs (activities of daily
living) and personal care. The proposed increase in PCA (personal care aide) to
total 48 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.