Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cognitive decline, dyslipidemia, hypothyroidism, goiter, coronary artery disease (CAD) status post coronary artery bypass grafting (CABG), gastroesophageal reflux disease (GERD), osteoarthritis, peptic ulcer, glaucoma, hypertension, atrial fibrillation on Eliquis, gastrointestinal (GI) bleed
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 56 Hours per Week
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total Amount of 56 Hours per Week
The denial is upheld.

The patient is an elderly female with a history of general debility. The request is for Personal Care Assistance through Home Health Care (Level 2) to be 56 hours per week (8 hours per day, 7 days per week) based on Uniform Assessment System (UAS) 5 months ago, but the health plan only approved 28 hours per week (4 hours per day, 7 days per week). The health plan denied the request because the patient is able to walk with the assistance of a cane, bathe herself with some assistance, and time is already allotted for meal preparation and light housekeeping. Transportation to and from medical appointments is provided to the patient as a plan benefit, and she lives with her daughter who is supportive and involved in her care. A recommendation was made by the health plan for her to adjust the service hours to better suit her needs as they are against an increase in hours. 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. The patient's daughter directs her care. A review of the records showed that the patient has multiple chronic medical conditions including cognitive decline, dyslipidemia, hypothyroidism, goiter, coronary artery disease (CAD) status post coronary artery bypass grafting (CABG), gastroesophageal reflux disease (GERD), osteoarthritis, peptic ulcer, glaucoma, hypertension, atrial fibrillation on Eliquis, gastrointestinal (GI) bleed, etc. 

The requested health service is not medically necessary.

The increase to 56 hours per week (8 hours per day, 7 days per week) based on Uniform Assessment System (UAS) of some  months ago - personal care is not medically necessary based on the patient's level of independence and supervision needed for her activities of daily living. The reasons alluded by the health plan as reasons for denial do reflect the findings in the Uniform Assessment System report of some months ago as summarized in the clinical summary above. Based on the most recent Uniform Assessment System, the patient is moderately impaired cognitively; independent with walking, locomotion, eating, and bed mobility; requires supervision with upper body dressing, personal hygiene, and toilet transfer; requires limited assistance with lower body dressing and toilet use; and requires extensive assistance with bathing, etc. Her family support is very good as she lives with the daughter. The reasons for denial by the health plan as stated in the clinical information above do align with her disability features as stated in the Uniform Assessment System of some months ago. Therefore, the 56 hours per week (8 hours per day, 7 days per week) requested should not be approved because the patient is independent to supervision with many of the activities of daily living and the hours allotted are adequate for the required help also aided by her daughter.