Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myelodysplastic syndrome
Treatment: Increase Personal Care Services (PCS) , 8 Hours Per Day 5 Days A Week and 5 Hours A Day, 2 Days A Week

The insurer denied the Increase Personal Care Services (PCS) , 8 Hours Per Day 5 Days A Week and 5 Hours A Day, 2 Days A Week.
The denial is upheld.

The patient is a female. She has conditions including myelodysplastic syndrome (MDS). Denial of increase personal care services (PCS), 8 hours per day 5 days a week and 5 hours a day, 2 days a week is being appealed. The plan approved 6 hours a day, 5 days a week and 5 hours a day, 2 days a week.

The patient's Uniform Assessment System (UAS) evaluation shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation and shopping; extensive assistance with bathing, dressing, walking, locomotion, and toilet use; limited assistance with managing medications, personal hygiene, and toilet transfer; supervisory with eating; and independent with bed mobility.  She uses a cane or walker for indoor ambulation with stand-by assistance. She has frequent bladder incontinence and infrequent bowel incontinence. There is no significant decline in functional status compared to UAS (Uniform Assessment System) evaluation completed previously.

A letter notes the patient has symptoms of MDS (myelodysplastic syndrome) including shortness of breath, weakness, fatigue, and difficulty ambulating. She requires weekly office visits, and these appointments require some attendants longer than currently allowed.

A letter notes the patient is receiving chemotherapy. She is oxygen dependent and uses wheelchair for ambulation. She has falls at home. Recommends additional hours.

No, the requested increase in Personal Care Services (PCS) to 8 Hours Per Day 5 Days A Week and 5 Hours A Day, 2 Days A Week 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 MDS (myelodysplastic syndrome) for which she is receiving chemotherapy. Denial of increase in PCS (personal care service), 8 hours per day 5 days a week and 5 hours a day, 2 days a week. The plan approved 6 hours a day, 5 days a week and 5 hours a day, 2 days a week.

Uniform Assessment System (UAS) evaluation shows the patient requires assistance with housework, meal preparation, shopping, bathing, dressing, walking, locomotion, toileting, medications, and personal hygiene. There is no significant decline in functional status compared to UAS (Uniform Assessment System) evaluation completed previously. Appeal statements note that the patient is currently receiving chemotherapy and requires longer hours with the aide for medical appointments. This patient's functional status has remained stable. The UAS (Uniform Assessment System) evaluations do not support additional hours. The PCS (personal care service) hours can be adjusted to meet the patient's needs for assistance during medical appointments. PCS (personal care service) is not indicated when no tasks are being performed. The currently approved PCS (personal care service) hours are appropriate and medically necessary to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase in PCS (personal care service) hours is not medically necessary.

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