Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma, osteoarthritis, dementia, hyperlipidemia, and hypertension.
Treatment: Increase Personal Care Aide (PCA) Services for a Total of 63 Hours Per Week
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total of 63 Hours Per Week
The denial is overturned.

The patient is an elderly female. Her conditions include asthma, osteoarthritis, dementia, hyperlipidemia, and hypertension. She had an admission last year due to behavioral changes. Denial of increase personal care aide (PCA) services for a total of 63 hours per week is being appealed. The plan approved 5 hours per day, 7 days per week, for a total of 35 hours per week.
The patient's Uniform Assessment System (UAS) evaluation completed 3 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, 
housework, and managing finances and medications; maximal assistance with phone use; extensive assistance with bathing, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility; and supervision with eating. She has frequent bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline with upper body dressing and personal hygiene.
A statement from the patient's designee notes that the patient is homebound and unable to independently perform ADLs (activities of daily living). Her health is worsening. She lives with her daughter and granddaughter. However, she is left home alone for an hour after the attendant leaves and before her daughter gets home. She is forgetful, confused and wanders when left alone. She is weak due to arthritis and uses a walker for ambulation. An increase in PCA (personal care aide) hours is requested to assist with completion of ADLs (activities of daily living). A letter from the patient's provider notes that the patient is dependent on others to complete ADLs (activities of daily living). She is homebound and requires assistance with locomotion. She requires prompting and assistance with morning and evening routines. She requires cuing due to dementia.

The requested Increase Personal Care Aide (PCA) Services for a Total of 63 Hours Per 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 63 hours per week is being appealed. The plan approved 5 hours per day, 7 days per week, for a total of 35 hours per week. This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation 
completed 3 months ago shows she needs assistance with all ADLs (activities of daily living), except eating. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline with upper body dressing and personal hygiene. The appeal statements indicate the patient is homebound and support the patient's the need for assistance with all ADLs (activities of daily living). The information provided show that this patient has significant limitations in functioning. The approved PCA (personal care aide) 35 hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase of PCA (personal care aide) to 63 hours per week is medically necessary.