Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Glaucoma/legal blindness, CHF (congestive heart failure), diabetes, end stage renal disease, syncope, and sleep apnea. 
Treatment: Increase Personal Care Aide (PCA) Services From 48 Hours Per Week To 84 Hours Per Week. 

The insurer denied the Increase Personal Care Aide (PCA) Services From 48 Hours Per Week To 84 Hours Per Week. 

The denial is upheld. 

The patient is a female. Her medical conditions include glaucoma/legal blindness, CHF (congestive heart failure), diabetes, end stage renal disease, syncope, and sleep apnea.  She lives with her spouse.  Denial of increase Personal Care Aide (PCA) services from 48 hours per week to 84 hours per week, is being appealed. 

UAS (Uniform Assessment System) evaluation completed shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with bathing, lower body dressing, walking, locomotion, and toileting; limited assistance with managing finances and medications, personal hygiene, and upper body dressing; and independent with bed mobility and eating.  She has bowel and bladder incontinence.  Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with managing medications, walking, locomotion, and toileting. 

An appeal letter notes the patient has frequent episodes of exertional dyspnea and syncope.  The letter notes the patient has fallen and passed out when her aide is not present.  It notes the patient's ability to perform ADLs (activities of daily living) has declined. 

A letter from the patient's provider notes the patient is legally blind and needs additional hours for supervision and assistance with ADLs (activities of daily living). 

A letter from another doctor notes the patient has multiple episodes of syncope in the past and needs extended hours for supervision and assistance with ADLs (activities of daily living). 

A letter from another provider notes the patient recommends ongoing assistance due to her current medical condition. 

No, the Increase Personal Care Aide (PCA) Services From 48 Hours Per Week To 84 Hours Per Week is not 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 from 48 hours per week to 84 hours per week is being appealed. 

This patient has several chronic medical conditions, including recurrent syncope. UAS (Uniform Assessment System) evaluation completed shows the patient requires maximal assistance with meal preparation, housework, and shopping; and extensive assistance with bathing, lower body dressing, walking, locomotion, and toileting. She requires limited assistance with managing finances and medications, personal hygiene, and upper body dressing. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with managing medications, walking, locomotion, and toileting. Appeal letters note the patient has syncope and falls and requests additional hours for supervision and assistance with ADLs (activities of daily living). PCA (personal care aide) is not indicated for supervision or to manage medical conditions. The PCA (personal care aide) is not able to prevent syncope. The documentation does not support that the proposed PCA (personal care aide) 84 hours are medically necessary to meet this patient's needs for assistance with ADLs (activities of daily living) and personal care. The currently approved PCA (personal care aide) 48 hours per week is sufficient to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.