Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative colitis, myelofibrosis, atrial fibrillation, sacral pressure ulcer, and muscle weakness.
Treatment: Increase Personal Care Services to 12 hours a day, 7 days a week, a total of 84 hours a week.
The insurer denied the Increase Personal Care Services to 12 hours a day, 7 days a week, a total of 84 hours a week.
The denial is overturned.

This female has conditions including ulcerative colitis, myelofibrosis, atrial fibrillation, sacral pressure ulcer, and muscle weakness.  She is appealing denial of personal care services (PCS) at 84 hours per week.  She was approved for 56 hours per week.  Uniform Assessment System (UAS) evaluation performed shows minimally impaired cognition and functional status: total dependence with housework; maximal assisted with meal preparation, and shopping; extensive assistance with managing finances and medications, bathing, dressing, walking, locomotion, and toilet transfer; limited assistance with phone use, personal hygiene, toilet use and bed mobility; and supervision with eating.  She ambulates and transfers with a walker.  She is frequently incontinent of bladder and infrequently incontinent of bowel.  Appeal letter the patient's provider notes the patient was admitted to a nursing home for rehab.  Since admission she had a significant decline in functional, cognitive and medical status and now requires extensive assistance with activities of daily living (ADLs).  Progress  reports from the nursing home note frequent turning and positioning for pressure ulcer.

Yes, the proposed treatment, Increase Personal Care Services to 12 hours a day, 7 days a weak, a total of 84 hours a week, is medically necessary.
Medically necessary services are those which are:
1) safe.  2) effective. 3) generally accepted national standard of medical practice. 
4) not provided primarily for convenience of the patient or the practitioner. 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice.

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 is appealing denial of 84 personal care service (PCS) hours per week.  She has been approved for 56 hours based on a Uniform Assessment System (UAS) assessment performed.  The assessment showed the patient requires assistance with all activities of daliy living (ADLs) with the exception of eating.  Since this assessment, the patient was admitted to a nursing home for rehab.  Appeal letter from nursing home provider states the patient has a significant decline in functional, cognitive and medical status.  The nursing home records show the patient has a sacral pressure ulcer and requires frequent turning and positioning.  As a result of reported decline in the patient's functioning and need for turning/positioning due to sacral pressure ulcer, the approved 56 hours is inadequate to meet the patient's needs.  The proposed increase in personal assistant services (PAS) to total 84 per week is medically necessary to meet this patient's needs for assistance with activities of daily living (ADLs) and personal care as outlined above.