Diagnosis: Multiple sclerosis, urinary and bowel
incontinence, anxiety, hyperlipidemia and
narcolepsy.
Treatment: Personal Aide (PCA) Services 70 Hours per Week, Pre-service
The insurer denied the Personal Aide (PCA) Services 70 Hours per Week, Pre-service
The denial is overturned.

This male has conditions including multiple sclerosis, urinary and bowel incontinence, anxiety, hyperlipidemia and narcolepsy. He is wheelchair bound due to multiple sclerosis (MS). He is appealing denial of personal care aide (PCA) 70 hours per week. He has been approved for personal care aide (PCA) 27.5 hours per week.

Uniform Assessment System (UAS) evaluation completed shows cognition is modified independent and functional status: total dependence with housework, stairs, walking, and locomotion; maximal assistance with meal preparation, managing medications, shopping, bathing, personal hygiene, dressing, toileting, and bed mobility; extensive assistance with managing finances; limited assistance with eating; and supervision with phone use. He uses a wheelchair and scooter for locomotion. He has bowel and bladder incontinence. Compared to Uniform Assessment System (UAS) evaluation performed a month prior, it is remarkable for decline in eating from independent to limited assistance. The patient was hospitalized with COVID pneumonia.

Appeal statement from New York states the patient needs assistance with activities of daily living (ADLs) as already accounted for in the Uniform Assessment System (UAS) evaluation due to advanced age and multiple medical conditions. His primary care physician (PCP) recommends increase in care due to the patient being wheelchair bound as a result of multiple sclerosis (MS).

Yes, the proposed treatment is medically necessary.
The proposed treatment is consistent with generally accepted standards 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 has multiple chronic conditions including multiple sclerosis. He is wheelchair bound. This patient requires assistance with all activities of daily living (ADLs) and personal care needs except phone use. Uniform Assessment System (UAS) evaluation completed compared to Uniform Assessment System evaluation completed a month prior is remarkable for decline in eating from independent to limited assistance. He has bowel and bladder incontinence.

Appeal statements recommend additional hours due to the patient's weakness resulting in him being wheelchair bound and needing assistance with all activities of daily living (ADLs) except phone use. As a result of this patient's weakness and inability to ambulate, he requires significant assistance with activities of daily living (ADLs) / instrumental activities of daily living (IADLs). The approved personal care aide (PCA) 27.5 hours per week is inadequate to meet this patient's needs. The proposed increase in personal care aide (PCA) 70 hours per week is medically necessary.