Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  COPD (chronic obstructive pulmonary disease), hypertension, hyperlipidemia, heart failure and atrial fibrillation
Treatment: Increase Personal Care Aid (PCA) Level II Services to 84 Hours Per Week (12 hours per day, 7 days per week)
The insurer denied: Increase Personal Care Aid (PCA) Level II 
Services to 84 Hours Per Week (12 hours per day, 7 days per week)
The denial is overturned.

The patient is an elderly female with history of general debility. The request is for increase of Personal Care Assistance through Home Health care (Level 2) to 84 hours per week (12 hours per day, 7 days per week) based on the UAS (Uniform Assessment 
System) evaluation of 5 months ago. The health plan approved an increase to 56 hours per week (8 hours per day, 7 days per week). The health plan denied coverage of the request, because the patient lives with her two daughters in a private home, and the patient is alert and oriented to person and place, considered safe to be left alone even though the family stated that she is never left alone, needs help with meal preparation, housekeeping, shopping, finances, medications, medical appointments, bathing, hygiene, dressing, locomotion, toileting, transfers, bed mobility and eating. The additional hours requested are because of the patient's chronic medical conditions, and to help with her Activities of Daily Living (ADLs), such as bathing, meal preparation, housekeeping, escorting to medical appointments, safety, supervision, etc. Her daughter directs her care. A review of the records showed that the patient has multiple chronic medical conditions, including COPD (chronic obstructive pulmonary disease), hypertension, hyperlipidemia, heart failure and atrial fibrillation, etc. The patient's UAS (Uniform Assessment System) evaluation of some months ago showed that the patient is totally dependent for meal preparation, housework, phone use, and shopping. She requires maximal assistance for managing medications, transportation, bathing, and lower body dressing. She requires extensive assistance for personal hygiene, upper body dressing, walking, locomotion, toilet transfer, and bed mobility. She requires limited assistance for eating, etc.
The patient's family support is very good, as she lives with two daughters and a son-in-law.

The requested Increase Personal Care Aid (PCA) Level II Services to 84 Hours Per Week (12 hours per day, 7 days per week) is medically necessary.

Based on the most recent UAS (Uniform Assessment System) evaluation, although her family support is very good, as she lives with her two daughters and son-in-law, the 
patient is totally dependent for meal preparation, housework, phone use, shopping, requires maximal assistance for managing medications, transportation, bathing, lower body dressing, requires extensive assistance for personal hygiene, upper body dressing, walking, locomotion, toilet transfer, bed mobility, requires limited assistance for eating, etc. The reasons cited by the health plan in their denial of coverage do not align with the patient's disability features as noted in the UAS (Uniform Assessment System) evaluation of some months ago, as stated above. Therefore, given the above, the increase in Personal Care Aid services to 84 hours per week (8 hours per day, 7 days per week) is medically necessary, because the patient is totally dependent and requires maximum assistance with most of her ADLs (activities of daily living).