Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, diabetes mellitus, coronary artery disease, hyperlipidemia, gastroesophageal reflux disease (GERD), osteoarthritis, and urinary incontinence
Treatment: Increase in Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week (Split Shift)
The insurer denied: Increase in Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week (Split Shift)
The denial is overturned.

The patient is an elderly male with a history of general debility due to dementia. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 84 hours per week (12 hours per day, 7 days per week) based on Uniform Assessment System (UAS) of last year to 168 hours per week (24 hours per day, 7 days per week) based on the Uniform Assessment System of 5 months ago. The health plan denied the request because the patient has a supportive daughter and son who can direct his care, the patient can walk with the assistance of a collator walker, can bathe with assistance, receives Meals on Wheels three meals a day, and his current needs are met by the previously allotted time of 12 hours per day. The additional hours requested are because of the patient's chronic medical conditions with a history of cerebrovascular accident (CVA) and frequent falls. He cannot be left unattended and there is a need for more assistance with his activities of daily living (ADLs) including bathing, personal hygiene, and meal preparation. A review of the records showed that the patient has multiple chronic medical conditions including dementia, diabetes mellitus, coronary artery disease, hyperlipidemia, gastroesophageal reflux disease (GERD), osteoarthritis, and urinary incontinence. Uniform Assessment System-New York (UAS-NY) evaluation of 5 months ago showed that the patient was severely cognitively impaired with confusion and hallucination. He required maximal assistance for bathing, upper body dressing, lower body dressing, walking, locomotion, toilet use/transfer, bed mobility, eating, and was totally dependent for meal preparation, housework, managing finances, managing medications, phone use, stairs, shopping, transportation, personal hygiene, etc. He lives alone in a 1-bedroom private house, and the children are supportive.

The requested health service is medically necessary.

The requested increase for Personal Care Assistance through Home Health Care (Level 2) from 84 hours per week (12 hours per day, 7 days per week) based on Uniform Assessment System (UAS) of last year to 168 hours per week (24 hours per day, 7 days per week) is medically necessary based on the most recent Uniform Assessment System of 5 months ago in which the patient was severely cognitively impaired with confusion and hallucination. He needs help with most activities of daily living as he requires maximal assistance for bathing, upper body dressing, lower body dressing, walking, locomotion, toilet use/transfer, bed mobility, eating, and was totally dependent for meal preparation, housework, managing finances, managing medications, phone use, stairs, shopping, transportation, and personal hygiene. The reason for denial by the health plan, as stated in the clinical information above, does not align with the patient's disability features as stated in the Uniform Assessment System of 5 months ago. Therefore, the 168 hours per week (24 hours per day, 7 days per week) based on the most recent Uniform Assessment System should be approved.