Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease.
Treatment: Increase Personal Care Aide (PCA) Services, Level II: 10 Hours per Day - 7 Days per Week - for a Total of 70 Hours per Week.
The insurer denied: Increase Personal Care Aide (PCA) Services, Level II: 10 Hours per Day - 7 Days per Week - for a Total of 70 Hours per Week.
The denial is overturned.

This elderly male has conditions including COPD, (Chronic Obstructive Pulmonary Disease) hypertension, renal failure, sleep apnea, neuropathy, restless legs syndrome, osteoporosis, and prostate cancer. Denial of an increase personal care aide (PCA) services, 10 hours per day, 7 days per week, for a total of 70 hours per week is being appealed. The plan approved 4 hours, 7 days per week, for a total of 28 hours per week. 
Uniform Assessment System (UAS) evaluation completed 4 months ago shows modified independent cognition and functional status: maximal assistance with meal preparation, 
housework, managing medications, and shopping; extensive use with stairs, transportation, bathing, lower body dressing, and toileting; limited assistance with managing finances, personal hygiene, upper body dressing, walking, locomotion, and bed mobility; and independent with eating. Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with toileting and bed mobility. He has frequent urinary incontinence. A letter from the Provider notes the member has multiple chronic conditions. He had a recent decline in mental health. He requires total assistance with all activities. He has increased toileting needs at night and requires assurance more than two hours per night. He lives alone and has no formal assistance.  A letter from the member's child notes he has several health issues and needs assistance with ADLs (activities of daily living) and doctors' appointments. He is currently undergoing treatment for metastatic prostate cancer and recently was diagnosed with Ramsey Hunt syndrome. 

The proposed treatment 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. This member has multiple chronic conditions. Denial of an increase personal care aide (PCA) services, 10 hours per day, 7 days per week, for a total of 70 hours per week is being appealed. The plan approved 4 hours, 7 days per week, for a total of 28 hours per week. The health plan denied an increase in hours based on Uniform Assessment System evaluations and notes that the member's personal care needs can continue to be met with the currently approved personal care aide (PCA) hours. 
Uniform Assessment System (UAS) evaluation completed 4 months ago shows he requires assistance with all ADLs (activities of daily living), except eating. Compared to Uniform 
Assessment System evaluation completed last year, there has been a decline with bed mobility. Compared to Uniform Assessment System evaluation completed last year, there 
has been a decline with toileting and bed mobility. He has frequent urinary incontinence. Appeal statements note there has been a decline in the member's medical and mental functioning. They note he requires assistance with all ADLs (activities of daily living), including overnight assistance with toileting. He lives alone and does not have informal support. The information provided shows that this member has significant limitations in functioning. His needs cannot be met with personal care aide (PCA) 28 hours per week. The approved personal care aide (PCA) 28 hours per week is insufficient to meet this member's needs for assistance with activities of daily living. The proposed increase to 70 hours per week is medically necessary.