Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mild cognitive impairment; diabetes mellitus, type 2; high blood pressure; high cholesterol; acid reflux; CKD (chronic kidney disease) stage 3; coronary heart disease; hypothyroidism; congestive heart failure; enlarged prostate; osteoarthritis; and status post CVA (cerebrovascular accident). 

Treatment:  Increase Personal Care Services level 2 To 12 Hours Per Day, 7 Days Per Week, Total of 84 Hours Per  Week. 

The insurer denied the  Increase Personal Care Services level 2 To 12 Hours Per Day, 7 Days Per Week, Total of 84 Hours Per  Week. 

The denial is overturned. 

The patient is a male. His medical conditions include mild cognitive impairment; diabetes mellitus, type 2; high blood pressure; high cholesterol; acid reflux; CKD (chronic kidney disease) stage 3; coronary heart disease; hypothyroidism; congestive heart failure; enlarged prostate; osteoarthritis; and status post CVA (cerebrovascular accident), old. He lives in an apartment with his disabled spouse in a building with elevator access. His wife is reported to have a split-shift from another MLTC (managed long term care). Denial of increase personal care services (PCS) to 12 hours per day, 7 days per week, total of 84 hours per week, is being appealed. The health plan approved 56 hours per week. 

Uniform Assessment System (UAS) evaluation performed shows modified independent cognition and functional status: total dependence with meal preparation, housework; maximal assistance with shopping; extensive assistance with managing medications, bathing, lower body dressing, toilet transfer, and toilet use; limited assistance with managing finances, personal hygiene, upper body dressing, walking, locomotion, and eating; and independent with bed mobility. The patient has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation previously, shows no significant decline in functional status. 

A letter from the patient's provider notes the patient has multiple chronic medical conditions. He has significant worsening of cognitive and functional status. He has dementia. He has increased gait instability with problems standing without assistance. He has cerebellar ataxia. He forgets to take his medications and is unable to prepare meals. 

Yes, the requested increase in personal care services to 84 hours per week is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 
Personal Care 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 PCS (personal care service) to 12 hours per day, 7 days per week, total of 84 hours per week, is being appealed. The health plan approved 56 hours per week. 

The patient has several chronic conditions. He lives with his disabled wife. Uniform Assessment System (UAS) performed shows the patient requires assistance with all ADLs (activities of daily living), except bed mobility. He has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there is no significant change in the patient's functional status. The appeal statement from his provider notes that the patient's cognitive and functional status have deteriorated. He has increased gait instability and requires assistance with standing. This patient has significant progressive cognitive and physical impairments. The approved PCS (personal care service) 56 hours per week is inadequate to meet the patient's needs for assistance with ADLs (activities of daily living)/IADLs (instrumental activities of daily living). The requested increase in PCS (personal care service) to a total 84 per week is medically necessary and appropriate to meets this patient's needs.