Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Short term memory loss, osteoarthritis, syncope, lumbosacral spondylosis, hypertension, gait disorder, and carpal and cubital tunnel disorder. 
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 126 Hours per week. 

The insurer denied: Increase Personal Care Aide (PCA) Services for a total amount of 126 hours per week. 

The denial is upheld. 

This elderly female patient has conditions including short term memory loss, osteoarthritis, syncope, lumbosacral spondylosis, hypertension, gait disorder, and carpal and cubital tunnel disorder. This is an appeal for denial of increase personal care aide (PCA) services for a total amount of 126 hours per week. The health plan approved 24 hours per week. The patient's son and niece are supportive in her care. Uniform Assessment System (UAS) evaluation completed 7 months ago shows moderately impaired cognition and functional status: total dependence with housework, managing finances, and shopping; maximal assistance with meal preparation, managing medications, and transportation; extensive assistance with bathing, lower body dressing, and toilet transfer; limited assistance with personal hygiene, upper body dressing, supervision with walking and locomotion; and independent with toilet use, bed mobility, and eating. She is continent of bowel and bladder. Compared to Uniform Assessment System (UAS) evaluation completed 2 years ago, there has been decline with upper body dressing and personal hygiene from independent to limited assistance and walking and locomotion from independent to supervision. A statement from the hospital notes the patient needs additional hours due to limited mobility and need for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient should not be left in a soiled diaper for long periods. A statement from the doctor notes the patient has conditions including dementia and osteoporosis. She is at increased fall risk. Additional hours are recommended for support at home and to facilitate attendance for frequent doctor visits. 

The proposed treatment 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 multiple chronic conditions. This is an appeal for denial of increase personal care aide (PCA) services for a total amount of 126 hours per week. The health plan approved 24 hours per week. Uniform Assessment System (UAS) evaluation completed 7 months ago shows the patient requires assistance with housework, managing finances, shopping, meal preparation, managing medications, transportation, bathing, lower body dressing, toilet transfer, personal hygiene, and upper body dressing. Compared to Uniform Assessment System (UAS) 
evaluation completed 2 years ago, there has been limited decline with upper body dressing and personal hygiene from independent to limited assistance and walking and locomotion from independent to supervision. She is continent of bowel and bladder. The patient's son and niece are supportive in her care. An appeal statement notes the patient needs assistance due to limited mobility. There has been no significant decline in the patient's functioning between Uniform Assessment System evaluations. Personal care services are not indicated for supervision or when no tasks are being performed. The information provided does not support a change in the patient's condition to support increasing personal care service (PCS) hours to 126 hours per week. The proposed increase in personal care services to 126 hours per week is not medically necessary. The approved personal care services of 24 hours per week is sufficient to meet this patient's needs.