Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, osteoarthritis, legal blindness, peripheral neuropathy, and chronic pain
Treatment: Increase Personal Care Aide (PCA) Services to 84 Hours per Week
The insurer denied Increase Personal Care Aide (PCA) Services to 84 Hours per Week.
The denial is overturned.

This is an elderly female patient that has medical conditions that include osteoporosis, osteoarthritis, legal blindness, peripheral neuropathy, and chronic pain. The denial of an increase in personal care aide (PCA) services to 84 hours per week is being appealed. The health plan approved a total of 56 hours per week. Uniform Assessment System (UAS) evaluation completed 3 months ago shows minimally impacted cognition and the patient requires assistance with all activities of daily living (ADLs). She has frequent bladder incontinence. Compared to the Uniform Assessment System evaluation completed 7 months ago, there has been a decline with upper body dressing, personal hygiene, toilet transfer, walking, eating, and bed mobility. A letter from the Provider notes the patient needs an increase in hours for safety with activities of daily living. She has a history of frequent falls with fractures. Her pain medications cause confusion. She cannot be safely left alone. A letter from another Provider notes the patient requires additional hours for assistance with activities of daily living to continue living independently in her home. A letter from the patient notes her medical conditions have declined. She requires assistance with activities of daily living. She is a fall risk. Another letter notes the patient has more difficulty with walking since hospitalization for pulmonary embolism. She has pain and weakness affecting her mobility. She isolates herself to her bedroom because she does not feel safe walking. Another letter from a different Provider notes the patient has been receiving physical therapy for 7 months. She is unable to complete her activities of daily living. A letter notes the patient has chronic pain. Her medical conditions have progressed and resulted in functional dependence. 
She had fallen many times. She recently suffered a coccyx fracture after a fall. She cannot be safely left alone. She requires supervision to safely navigate her home. A letter notes there has been a steady decline in the patient's physical abilities. Another letter notes the patient has knee and shoulder conditions that affect her ability to walk and stand for prolonged periods. She is unable to lift, push, or pull. She requires supervision to safely navigate her home.

The proposed treatment is medically necessary. 

This patient has multiple chronic conditions. She lives alone. The denial of an increase in personal care aide (PCA) services to 84 hours per week is being appealed. The health plan approved a total of 56 hours per week. Uniform Assessment System evaluation completed 3 months ago shows the patient requires assistance with all activities of daily living. She has frequent bladder incontinence. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been decline with upper body dressing, personal hygiene, toilet transfer, walking, eating, and bed mobility. Appeal statements note there has been a deterioration in the patient's physical functioning and cognition related to medications. She is a fall risk. She has been isolating to her bedroom due to fear of falling without assistance. The information provided shows that this patient has significant limitations in functioning as supported by Uniform Assessment System evaluations. Due to her limited mobility and need for assistance with all activities of daily living, the approved personal care aide 56 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 84 hours per week is medically indicated.