Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus, hypertension, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD) with emphysema, goiter, hyperlipidemia, chronic diarrhea, liver cancer
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 30 Hours Per Week
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total Amount of 30 Hours Per Week
The denial is overturned.

The patient is an elderly male with a history of general debility. The request was for Personal Care Assistance through Home Health care (Level 2) to be increased from 20 hours per 
week (four hours per day, five days per week) based on Uniform Assessment System (UAS) of last year to 30 hours per week (six hours per day, five days per week) based on Uniform Assessment System of 8 months ago. The health plan denied the request, noting that the patient can direct his own care, and that he lives with his spouse, with his son and daughter being supportive of his care. In addition, the allotted time is adequate to meet his needs for housework, laundry, and meal preparation. The additional hours requested are because of his chronic medical conditions and to help with his activities of daily living (ADLs). He has difficulties in sitting, standing for a prolonged time, climbing stairs, bathing, dressing, grooming, feeding, ambulating, preparing food, and shopping. He is at a high risk of falls. A review of the records showed that patient has multiple chronic medical conditions, including diabetes mellitus, hypertension, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD) with emphysema, goiter, hyperlipidemia, chronic diarrhea, liver cancer status post radiation therapy while awaiting chemotherapy, pancreatic nodule, and generalized osteoarthritis. The patient's Uniform Assessment System (UAS) evaluation of 8 months ago showed that he is cognitively intact with modified independence with some difficulty in new situations only, required setup or independent for phone use, personal hygiene, toilet use, bed mobility, eating; required limited assistance with managing medications, managing finances, upper body dressing, walking, locomotion, toilet transfer; required extensive assistance with transportation, lower body dressing; required maximal assistance for meal preparation, shopping, bathing; and was totally dependent for housework, etc. His family support is very good, as he lives with his spouse, with his son and daughter also providing additional support.

The requested Increase Personal Care Aide (PCA) Services for a Total Amount of 30 Hours Per Week is medically necessary.

The requested increase for Personal Care Assistance through Home Health care (Level 2) from 20 hours per week (four hours per day, five days per week) to 30 hours per week (six hours per 
day, five days per week) is medically necessary, because the patient is cognitively intact with modified independence with some difficulty in new situations only, required setup or 
independent for phone use, personal hygiene, toilet use, bed mobility, eating. He required limited assistance with managing medications, managing finances, upper body dressing, walking, 
locomotion, toilet transfer; required extensive assistance with transportation, lower body dressing; required maximal assistance for meal preparation, shopping, bathing, and was totally dependent for housework. The reason for denial by the health plan as stated in the clinical information above, does not align with the disability features as stated in the Uniform Assessment System 8 months ago. Therefore, the 30 hours per week (six hours per day, five days per week) requested is medically necessary.