Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVID (coronavirus disease) pneumonia and acute hypoxic respiratory failure
Treatment: Increase Personal Care Aide (PCA) Level II: 12 Hours a Day, 7 Days a Week for a Total of 168 Hours per Week
The insurer denied the Increase Personal Care Aide (PCA) Level II: 12 Hours a Day, 7 Days a Week for a Total of 168 Hours per Week
The denial is overturned

This female patient has multiple chronic conditions, include recent COVID pneumonia and acute hypoxic respiratory failure. She lives alone. She is appealing denial of increase in personal care aide (PCA), 12 hours a day, seven days a week, for a total of 168 hours per week. The health plan approved personal care aide (PCA) ten hours a day, seven days a week for a total of 70 hours per week.  

Uniform Assessment Systems (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, shopping, transportation bathing, personal hygiene, dressing, locomotion, toileting, bed mobility, and eating; and maximal assistance with phone use.  She has bowel and bladder incontinence. Compared to Uniform Assessment Systems (UAS) evaluation completed previously, the patient has declined in all areas.	 
A statement reports the patient requires maximal assistance with activities of daily living (ADLs) and unscheduled tasks during the day and night and that an aide could not get five hours of uninterrupted sleep.

Night logs show the patient receiving frequent assistance with activities of daily living (ADLs), including toileting and repositioning.

Yes, the proposed treatment is medically necessary.
Personal Care 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 several chronic conditions. She is appealing denial of increase in personal care aide (PCA) 12 hours a day, seven days a week for a total of 168 hours per week. The health plan approved personal care aide (PCA) ten hours a day, seven days a week for a total of 70 hours per week.  

Uniform Assessment Systems (UAS) evaluation completed shows the patient requires assistance with all activities of daily living. She has bowel and bladder incontinence.  Compared to Uniform Assessment Systems (UAS) evaluation completed previously, the patient has declined in all areas. The appeal statement notes the patient has unscheduled tasks during the day and night and that an aide could not get five hours of uninterrupted sleep. Night logs show the patient receiving frequent assistance with activities of daily living (ADLs), including toileting and repositioning. This patient has significant physical impairments and requires frequent assistance with all activities of daily living (ADLs). The approved personal care aide (PCA) ten hours a day, seven days a week, for a total of 70 hours per week, is insufficient to meet the patient's needs. The proposed personal care aide (PCA) 12 hours a day, seven days a week for a total of 168 hours per week is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The proposed treatment is medically necessary.