Appeal type: Medical necessity
Decision: Overturned

Diagnosis: General debility, diabetes, congestive heart failure (CHF)
Treatment: Personal Care Assistance Services for a Total of 49 Hours per Week
The insurer denied: Personal Care Assistance Services for a Total of 49 Hours per Week
The denial is overturned.

The patient is an elderly female with a history of general debility. The request was for Personal Care Assistance to be increased from 24 hours per week based on Uniform Assessment System (UAS) of 9 months ago to 49 hours per week (7 hours per day, 7 days per week) based on Uniform Assessment System of 3 months ago. The health plan denied the request because the 
patient's needs are expected to improve in the near future. The partial increase allowed is expected to give her enough support for current activities of daily living including personal hygiene, upper body dressing, walking, locomotion, toilet transfer, toilet use, bathing, and lower body dressing. The additional hours requested are because of the patient's chronic medical conditions, and to help with her activities of daily living as she had a torn knee meniscus with the inability to stand or walk without physical support, an increased risk of falls, etc. A review of the records showed that the patient has multiple chronic medical conditions including coronary heart disease, depression, diabetes mellitus, heart failure, hypertension, congestive heart failure (CHF), history of breast cancer, hypercholesterolemia, glaucoma, and decreased balance with increased fall risks.
Uniform Assessment System-New York (UAS-NY) evaluation of 3 months ago showed that the patient was cognitively intact but forgetful at certain times; independent/set-up with eating and 
bed mobility; required limited assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, toilet use; required extensive assistance with meal preparation, managing finances, managing medications, transportation, lower body dressing, bathing; required maximal assistance for housework, stairs, shopping; and was totally dependent for meal preparation, housework, shopping, etc. The patient lives in a private home with her son.

The requested health service is medically necessary.

The requested increase for Personal Care Assistance from 24 hours per week based on Uniform Assessment System of 9 months ago to 49 hours per week (7 hours per day, 7 days per week) is medically necessary because based on the most recent Uniform Assessment System of 3 months ago the patient was cognitively intact but forgetful at certain times; independent/set-up with eating and bed mobility; required limited assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, toilet use; required extensive 
assistance with meal preparation, managing finances, managing medications, transportation, lower body dressing, bathing; required maximal assistance for housework, stairs, shopping; and was totally dependent for meal preparation, housework, and shopping. The reason for denial by the health plan, as stated in the clinical information above, does not align with the patient's disability features as stated in the Uniform Assessment System of 
3 months ago. Therefore, the 49 hours per week (7 hours per day, 7 days per week) based on the most recent Uniform Assessment System should be approved. The requested health service is medically necessary.