Diagnosis: Diabetes, dementia and multiple thyroid nodules.
Treatment: Increase Personal Care Aide (PCA) Services to the Amount of 84 Hours per Week.
The insurer denied the Increase Personal Care Aide (PCA) Services to the Amount of 84 Hours per Week.
The denial is overturned.

The patient is a female who reportedly has multiple co-morbidities including diabetes mellitus (DM), hypertension (HTN), coronary artery disease (CAD), claudication of right lower extremity, dementia and multiple thyroid nodules. The request is for an increase in personal care services. The patient has progressive functional decline. She lives alone. She needs help with all her activities of daily living (ADLs).

This is a review for an increase in personal care aide (PCA) services to 84 hours per week.

Yes, the proposed increase in personal care aide services to 84 hour per week is medically necessary.

This patient has multiple comorbidities and needs help with all her activities of daily living (ADLs). She lives alone on the second floor. She has recent functional decline in the past 90 days due to a fall and leg fracture. She has urinary incontinence as well. She has difficulty walking and is having dizziness on ambulation. She needs reminders for her medications. She needs more hours to ensure safety.

The health plan approved personal care aide services, level II: six hours per day - seven days per week, for a total of 42 hours per week is not enough to meet this patient's needs.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient needs extended hours.