Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease, vertigo, major depressive disorder and generalized anxiety disorder.
Treatment: Increase Personal Care Assistance (PCA) Services to Seven Days x Nine Hours per Week.
The insurer denied the Increase Personal Care Assistance (PCA) Services to Seven Days x Nine Hours per Week.
The denial is upheld.

This female patient has medical conditions including coronary artery disease, vertigo, major depressive disorder and generalized anxiety disorder.  She is appealing the denial of an increase in personal care assistance (PCA) services from seven days x six hours per week to seven days x nine hours per week.  

Evaluation performed notes the patient's functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with bathing, dressing, toileting, locomotion, and managing medications; supervision/limited assistance with personal hygiene; and independent with eating.  She was observed ambulating without assistance.  Compared to evaluation performed previously, there has been a decline in ability to perform personal hygiene, dressing, toileting, locomotion, meal preparation, housework, and shopping. 

An appeal letter from the provider notes the patient has increased anxiety and depression.  The letter states that the patient remains sick and requires increased hours of home care.  An appeal from the health plan notes the patient had a fall and broke her elbow.  This affects her ability to use her hand.  The letter notes that she is unstable on her feet. She has urinary incontinence and cannot change diapers.  She cannot get dressed or out of bed. An appeal letter from the provider notes the patient has several medical conditions and needs home health aide (HHA) eight hours per day, seven days per week.

No, the proposed treatment 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.  

This patient has several chronic medical conditions.  She is appealing denial of increase personal care assistance (PCA) services from seven days x six hours per week to seven days x nine hours per week.  She requires assistance with meal preparation, housework, and shopping; extensive assistance with bathing, dressing, toileting, locomotion, and managing medications. Evaluation of functional status performed most recently compared to the previous assessment shows there has been decline in the patient's functional status.  She was observed ambulating without assistance.  An appeal letters note that the patient has chronic conditions, is a fall risk due to instability, and has urinary incontinence.  The documentation provided does not support additional hours.  The assistance needed for activities of daily living ( ADLs) and instrumental activities of daily living (IADLs) can be scheduled.  Personal care assistance services are not indicated when no tasks are being performed or for safety supervision.  The approved personal care assistance services seven days x six hours per week is appropriate and medically necessary to meets the patient's needs for assistance with activities of daily living and personal care.  The proposed increase in personal care assistance services seven days x nine hours per week is not medically necessary.

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