Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibromyalgia, osteoarthritis and neuropathy.
Treatment: Increase Personal Care Assistance to 12 Hours Per Day 7 Days Per Week (Monday through Sunday) A Total of 84 Hours Per Week.
The insurer denied the Increase Personal Care Assistance to 12 Hours Per Day 7 Days Per Week (Monday through Sunday) A Total of 84 Hours Per Week.
The denial is upheld.

This female patient has conditions including hypertension, diabetes, hyperlipidemia, fibromyalgia, osteoarthritis and neuropathy.  She lives alone.  She was admitted to the hospital with a diagnosis of syncope.  She is appealing denial of increase in personal care assistance (PCA) to 12 hours per day, seven days per week, total of 84 hours per week.  She has been approved for personal care assistance (PCA) five hours per day, seven days a week, total of 35 hours per week.  

Uniform Assessment System (UAS) evaluation performed shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, stairs, and shopping; extensive assistance with bathing, dressing, walking, locomotion, and toileting; limited assistance with managing finances and medications and personal hygiene; independent with bed mobility; and supervision with eating.  She has impaired range of motion, coordination, and balance.  She has frequent bladder incontinence and infrequent bowel incontinence.  Compared to Uniform Assessment System (UAS) evaluation completed previously, there is no significant decline in the patient's functional status.

No, the proposed treatment 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.  This patient has multiple chronic medical conditions.  She has impaired range of motion, coordination, and balance.   She was hospitalized due to syncope.  She is appealing the denial of an increase in personal care assistance (PCA) to 12 hours per day, seven days per week, total of 84 hours per week.  

Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs) except bed mobility and eating (maximal assistance with meal preparation, housework, stairs, and shopping; extensive assistance with bathing, dressing, walking, locomotion, and toileting; limited assistance with managing finances and medications and personal hygiene).  She has frequent bladder incontinence and infrequent bowel incontinence.  The documentation does not support deterioration in the patient's functional status and need for increase personal care assistance (PCA) hours.  Personal care assistance (PCA) is not indicated for supervision or when no tasks are being performed.  The approved personal care assistance (PCA) 35 hours per week is adequate to meet the needs for assistance with activities of daily living (ADLs) and personal care.  The proposed increase in personal care assistance (PCA) to 12 hours per day, seven days per week, total of 84 hours per week is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.