Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, diabetes with neurologic and circulatory complications, sarcopenia, and generalized muscle weakness
Treatment: Personal Care Services (PCS), 1 day/week, 11 hours/day and 2 days/week, 12 hours/day, for a total of 35 hours/week
The insurer denied PCS, 1 day/week, 11 hours/day and 2 days/week, 12 hours/day, for a total of 35 hours/week.
The denial is upheld.

This elderly female patient has conditions including hypertension, diabetes with neurologic and circulatory complications, sarcopenia, and generalized muscle weakness. She lives alone. This is an appeal for denial of personal care services (PCS), 1 day/week, 11 hours/day and 2 days/week, 12 hours/day, for a total of 35 hours/week. The Plan approved 7 days/week, 4 hours/day, for a total of 28 hours/week. The Uniform Assessment System (UAS) evaluation completed 4 months ago shows modified independent cognition and functional status: maximal assistance with housework and shopping; extensive assistance with meal preparation and managing finances; limited assistance with managing medications, stairs, transportation bathing, lower body dressing, walking, locomotion, and toilet transfer; and independent with phone use, personal hygiene, upper body dressing, bed mobility, toilet use, and eating. Her daughter prepares meals and she is able to heat them in the microwave. She is continent of bowel and bladder. Compared to UAS evaluation completed 18 months ago, there is no change in cognition and her functional status has not declined. A letter from the patient's physician notes the patient needs an increase in hours due to her rapidly deteriorating mental state, physical health, and functional status. She is unable to walk without assistance and a walker. She cannot independently perform activities of daily living (ADLs).

The proposed treatment is not medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with ADLs, health maintenance activities, and routine support services. This patient has multiple chronic conditions. She is appealing denial of PCS, 1 day/week, 11 hours/day and 2 days/week, 12 hours/day, for a total of 35 hours/week. The health plan denied the request based on the UAS evaluations and support from the patient's daughter. The plan determined that time needed is 22.34 hours/week, but adjusted to approve 4 hours/day, 7 days/week, for a total of 28 hours/week. UAS evaluation completed 4 months ago shows the patient is independent with phone use, personal hygiene, upper body dressing, bed mobility, toilet use, and eating. She requires limited assistance with managing medications, stairs, transportation bathing, lower body dressing, walking, locomotion, and toilet transfer. Her daughter prepares her meals, and she can heat them in the microwave. Compared to UAS evaluation completed 18 months ago, her functional status has not declined. She has improved with upper body dressing and toilet use from limited assistance to independent. The appeal statement notes the patient's condition is rapidly deteriorating, and she cannot independently perform ADLs. Based on the patient's stability in functioning as compared by UAS evaluations and informal assistance of her daughter, the proposed PCS, 1 day/week, 11 hours/day and 2 days/week, 12 hours/day, for a total of 35 hours/week are not medically necessary. The approved PCS of 4 hours/day, 7 days/week, for a total of 28 hours/week is appropriate for this patient. The patient may adjust aide services to meet her needs.