Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall with wrist fracture; dementia; osteoarthritis
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 30 Hours per Week
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total Amount of 30 Hours per Week
The denial is overturned.

This elderly female patient has dementia. The patient was admitted to the hospital after a mechanical fall that resulted in a wrist fracture. She was found to have a thoracic compression fracture. The denial of an increase in personal care aide (PCA) services for a total amount of 30 hours per week is being appealed. The health plan approved personal care aide 3.5 hours per day, 5 days per week, for a total of 17.5 hours per week.

Uniform Assessment System (UAS) evaluation completed 3 months ago shows moderately impaired cognition and functional status: total dependence with housework, managing finances and medications; maximal assistance with meal preparation, phone use, shopping, and transportation; and supervision with bathing, personal hygiene, dressing, walking, locomotion, bed mobility, and eating. Compared to Uniform Assessment System evaluation completed 5 months ago, there has been a decline in cognition. A letter from the patient's physician notes the patient has chronic medical conditions and requires assistance with activities of daily living (ADLs), including ambulation, toileting, transferring, bathing, dressing, and meal preparation. The patient's history includes dementia, osteoarthritis, hypertension, diabetes, and metabolic encephalopathy. A letter from the patient's grandson notes the patient lives alone. She has chronic progressive medical conditions. Re-assessment of her level of need is requested.

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, a recent wrist fracture and thoracic compression fracture after a fall. The denial of an increase in personal care aide (PCA) services for a total amount of 30 hours per week is being appealed. The health plan approved personal care aide 3.5 hours per day, 5 days per week, for a total of 17.5 hours per week. The health plan determined that an increase in hours was not indicated based on Uniform Assessment System (UAS) evaluations completed 4 months ago and 5 months ago showing no change in physical functioning. Uniform Assessment System evaluation completed 4 months ago shows the patient needs assistance with housework, managing finances and medications, meal preparation, phone use, shopping, and transportation. Compared to Uniform Assessment System evaluation completed 5 months ago, there has been a decline in cognition. The appeal information shows the patient was hospitalized with fractures after a fall. Her provider reports that she needs assistance with activities of daily living. She lives alone. The appeal information provided shows that this patient has significant limitations in functioning that have progressed after the fall. The approved personal care aide 17.5 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 30 hours per week is medically necessary.