Appeal type: Medical necessity
Decision: Overturned

Diagnosis: rheumatoid arthritis, muscle weakness, poor inductance, chronic pain, diabetes, and neuropathy
Treatment: Increase Personal Care Services to 12-24 Hours A Day, (live-in), 91 hours/week
The insurer denied the Increase Personal Care Services to 12-24 Hours A Day, (live-in), 91 hours/week
The denial is overturned, in part.

The patient is a female. She has medical conditions including rheumatoid arthritis, muscle weakness, poor inductance, chronic pain, diabetes, and neuropathy. This is an appeal of denial for increase Personal Care Services to 12-24 hours per day, live-in, total up to 91 hours per week. The Plan approved PCS (personal care services) 41 hours per week. The patient's daughter has requested an increase for safety supervision and assistance with ADLs (activities of daily living).

An appeal letter from the patient's daughter is requesting an increase 8-10 hours to assist with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation. An appeal statement from the patient's provider notes the patient had a functional decline. States the patient has frequent unscheduled needs and needs frequent change due to urinary incontinence. An appeal statement notes the patient's condition has declined over the past few months, resulting increased needs for assistance. States the patient is no longer able to independently reposition in bed. The report notes decline in functioning when comparing fall of last year to early summer this year: increase from limited to extensive assistance with ambulation, toileting, personal hygiene, and upper body dressing; and max assistance with bathing and lower body dressing. She requires a walker for ambulation. She has incontinence.

Yes, in part. The Increase Personal Care Services to 12-24 Hours A Day, (live-in), 91 hours/week is medically necessary, in part. Specifically, an increase in personal care services to 56 hours/week is medically necessary.
Personal Care Services provide hands-on assistance to individuals to include the following: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions. This is an appeal of denial for increase Personal Care Services to 12-24 hours per day, live-in, 91 hours per week. The Plan approved PCS (personal care services) 41 hours per week.

The daughter is requesting an increase in hours for supervision and to assist with ADLs (activities of daily living). Per the appeals, there has been a decline in the patient's functioning from UAS (Uniform Assessment System) evaluations performed previously, showing an increase from limited to extensive assistance with ambulation, toileting, personal hygiene, and upper body dressing; and max assistance with bathing and lower body dressing. The patient has incontinence and is unable to reposition herself in bed. This patient requires significant assistance with ADLs (activities of daily living). PCS (personal care services) is not indicated for supervision. However, the approved PCS (personal care services) 41 hours per week is insufficient to meet the needs as noted above. The proposed increase in PCS (personal care services) 12-24 hours per day is not medically necessary to meets this patient's needs for assistance with ADLs (activities of daily living) and personal care. Based on the decline in this patient's functional status, an increase PCS (personal care services) to 8 hours per day, 56 hours per week, is appropriate to meet this patient's needs.