Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease, oxygen dependent chronic obstructive pulmonary disease, heart failure, rheumatoid arthritis, hand and foot deformities, and diabetes. 
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 84 Hours Per Week. 

The insurer denied: Increase Personal Care Aide (PCA) Services for a Total Amount of 84 Hours Per Week. 

The denial is upheld.

The patient is an elderly female. Her medical conditions include coronary artery disease, oxygen dependent chronic obstructive pulmonary disease, heart failure, rheumatoid arthritis, hand and foot deformities, and diabetes. Denial of increase personal care aide (PCA) services for a total amount of 84 hours per week is being appealed. The health plan approved 59.5 hours per week. The health plan noted that Uniform Assessment System (UAS) evaluation performed 2 months ago shows no significant change compared to UAS (Uniform Assessment System) evaluation completed 4 months ago. The appeal request form notes that the patient has a decline in health, progression in hand pain. It notes that she is unable to move her back, and she needs assistance with ADLs (activities of daily living). Her daughter is no longer able to provide support. A letter from a provider notes that the patient's daughter has multiple medical conditions and cannot care for her mother. A letter from another provider notes that the patient needs additional hours due to her medical conditions and for assistance with ADLs (activities of daily living). Additional appeal letters note that the patient's health is deteriorating, and she needs assistance with ADL's (activities of daily living). The patient's daughter is no longer able to provide support. The provider states the UAS (Uniform Assessment System) evaluation is inaccurate, because the home attendant was present during the interview. There are medical records supporting the daughter's medical treatment. 

The requested Increase Personal Care Aide (PCA) Services for a Total Amount of 84 Hours Per Week 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. Denial of increase personal care aide (PCA) services for a total amount of 84 hours per week is being appealed. The health plan approved 59.5 hours per week. This patient has several chronic conditions. The health plan noted that Uniform Assessment System (UAS) evaluation performed 2 months ago, shows no significant change compared to UAS (Uniform Assessment System) evaluation completed 4 months ago. UAS (Uniform Assessment System) evaluations have not been provided for review. Appeal statements report a decline in the 
patient's health and loss of support from her daughter. The information provided is inadequate to support medical necessity for increased PCA (personal care aide) hours from 59.5 to 84 hours per week. PCA (personal care aide) is not indicated when no tasks are being performed or for supervision. The requested PCA (personal care aide) 84 hours per week is not medically necessary.