Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, arthritis, hypertension, and heart disease
Treatment: Increase in Personal Care Assistance (PCA) services to 9 hours/day, 7 days/week, for a total of 63 hours/week
The insurer denied the increase in PCA services to 9 hours/day, 7 days/week, for a total of 63 hours/week.
The denial is upheld.

This female patient has conditions including diabetes, arthritis, hypertension, and heart disease.  She is appealing denial of increase in personal care assistance (PCA) services, 9 hours/day, 7 days/week, for a total of 63 hours/week.  There has been a change in the patient's social circumstances as her daughter is no longer able to provide informal care due to her own health issues.  The health plan approved PCA 9 hours/day, 5 days/week, for a total of 45 hours/week.  

Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation and shopping; extensive assistance with managing finances and medications, bathing, lower body dressing, and toileting; limited assistance with phone use, personal hygiene, upper body dressing, walking, and locomotion; supervision with eating; and independent with bed mobility.  She has frequent bladder incontinence.  UAS evaluation performed previously shows more assistance needed with housework and managing finances and medications.  Otherwise, there is no significant change in the patient's functioning.  An appeal statement notes the increase in hours is needed due to the patient's advanced age and multiple conditions.  Her provider notes that her condition has declined, she is mostly bed or chair bound, and at high risk for falls.  A letter from the provider notes that the patient has multiple medical problems.  She is mostly bed/chair bound and needs assistance with transfers.  She is a high fall risk.  It notes she needs assistance with activities of daily living (ADLs) as already accounted for in the UAS evaluation.

No, the proposed treatment, increase in PCA services to 9 hours/day, 7 days/week, for a total of 63 hours/week is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with ADLs, health maintenance activities, and routine support services.  

This patient has several chronic conditions.  She is appealing denial of an increase in PCA services to 9 hours/day, 7 days/week, for a total of 63 hours/week.  The health plan approved PCA 9 hours/day, 5 days/week, for a total of 45 hours/week.  UAS evaluation completed shows the patient requires assistance with all ADLs, except bed mobility and eating.  She has frequent bladder incontinence.  Compared to UAS evaluation performed previously, there is no significant change in the patient's functioning.  It shows more assistance needed with housework and managing finances and medications.  An appeal statement notes that the patient's condition is declining.  It states the patient is mostly bed or chair bound and needs assistance with transfers.  The information provided shows no significant change in the patient's cognition and functional status between UAS evaluations performed.  The approved personal care services (PCS) 45 hours per week are appropriate and medically indicated to meet the patient's needs for assistance with ADLs and personal care.  PCS are not indicated for supervision or when no tasks are being performed.  The proposed increase in PCS to total 63 hours/week is not medically necessary.

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