Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, morbid obesity, osteoarthritis
Treatment: Personal Care Services Level II - Increase to 12 
hours per day, 7 days per week, for a total 84 hours per week
The insurer denied: Personal Care Services Level II - Increase to 12 hours per day, 7 days per week, for a total 84 hours per week
The denial is overturned.

This adult female has medical conditions that include osteoarthritis, spine surgery, obesity, and coronary artery disease. The patient reports being homebound and is unable to stand from bed due to back pain. The denial of personal care services level II - increase to 12 hours per day, 7 days per week, for a total 84 hours per week is being appealed. The health plan approved 63 hours per week. 
Uniform Assessment System evaluation performed six months ago shows modified independent cognition and functional status: total dependence. with housework, transportation, locomotion, and toilet transfer; maximal assistance with meal preparation, shopping, bathing, and lower body dressing; extensive assistance with toilet use; limited assistance with managing finances and medications, personal hygiene, upper body dressing, and bed mobility; and supervision with eating. The patient uses a wheelchair and scooter for locomotion. She has frequent bladder incontinence. Compared to Uniform Assessment System evaluation completed a year earlier, there has been a decline in functional status with housework, managing medications, transportation, toilet transfer, bed mobility, locomotion, and eating. 
A letter from the Provider notes the patient has multiple medical conditions and had spinal surgery seven months ago. She is bed bound and unable to position herself. She requires repositioning every two to three hours. She is unable to stand due to muscle spasms and pain.

The proposed treatment is 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. She reports herself as being homebound. The denial of personal care services level II - increase to 12 hours per day, 7 days per week, for a total 84 hours per week is being appealed. The health plan approved 63 hours per week. Uniform Assessment System evaluation performed six months ago shows the patient requires assistance with all activities of daily living (ADLs), except eating. She has frequent bladder incontinence. Compared to Uniform Assessment System (UAS) evaluation completed a year earlier, there has been a decline in functional status with housework, managing medications, transportation, toilet transfer, bed mobility, locomotion, and eating. The appeal statement from the patient's provider states the patient is bedbound and needs assistance with repositioning every two to three hours, but this is not supported by the patient's statement or Uniform Assessment 
System evaluation. The information provided shows that this patient has significant limitations in functioning that have progressed between Uniform Assessment System evaluations. The approved personal care services of 63 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 84 hours per week is medically necessary.