Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, heart failure, coronary artery disease, anemia, asthma, and debility
Treatment: Increase Personal Care Services (PCS) 7 hours a day, 7 days a week for a total of 49 hours per week
The insurer denied: Increase Personal Care Services (PCS) 7 hours a day, 7 days a week for a total of 49 hours per week
The denial is overturned.

The patient is an adult female. Her conditions include diabetes, heart failure, coronary artery disease, anemia, asthma, and debility. She was hospitalized 3 months ago with decompensated heart failure. She lives alone. Denial of increase personal care services (PCS) 7 hours a day, 7 days a week for a total of 49 hours per week is being appealed. The plan approved 7 hours a day, 3 days a week for a total of 21 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 2 months ago shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, stairs, and shopping; extensive assistance with managing finances and medications, transportation, bathing, dressing, and toilet transfer; limited assistance with personal hygiene and toilet use; and supervision with walking, locomotion, bed mobility, and eating. She has frequent bowel and bladder incontinence.
The order from the patient's provider notes that the patient lives alone and has no support. She has chronic pain. She needs help with ADLs (activities of daily living). A statement from the patient's provider notes the patient is dependent for her ADLs (activities of daily living). She needs an increase in home care hours due to worsening chronic debility.

The requested Increase Personal Care Services (PCS) 7 hours a day, 7 days a week for a total of 49 hours per week 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. Denial of increase personal care services (PCS) 7 hours a day, 7 days a week for a total of 49 hours per week is being appealed. The plan approved 7 hours a day, 3 days a week for a total of 21 hours per week. The plan denied an increase in hours based on the UAS (Uniform Assessment System) evaluation. The plan does not provide time for companionship, safety supervision, or when no tasks are being performed. This patient has multiple chronic conditions and was recently hospitalized with heart failure. Uniform Assessment System (UAS) evaluation completed 2 months ago shows she requires assistance with all ADLs (activities of daily living), except walking, locomotion, bed mobility, and eating. She has frequent bowel and bladder incontinence. The appeal statements note the patient needs increased hours of assistance due to worsening debility. She lives alone and has no support. This patient needs assistance with meal preparation, housework, stairs, shopping, managing finances and medications, transportation, bathing, dressing, toileting, and personal hygiene. The approved PCS (personal care service) 21 hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase to 49 hours per week is medically necessary.