Diagnosis: Chronic medical conditions, bowel/bladder incontinence.
Treatment: Increase Personal Care Services (per 15 minutes) to 70 Hours per Week.

The insurer denied: Increase Personal Care Services (per 15 minutes) to 70 Hours per Week.
The denial is overturned.

This patient is an elderly female who has multiple chronic medical conditions (constipation, arthritis, tremor, vascular dementia, urinary/bowel incontinence). She is appealing denial of increase personal care services to 70 hours per week. The plan approved an increase from 45 to 56 hours per week.

Uniform Assessment System (UAS) evaluation recently completed shows the patient has moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, bathing, personal hygiene, dressing, locomotion, ant toileting; and maximal assistance with managing medication, phone use, bed mobility and eating. The patient is bed bound. She is incontinent of bowel and bladder. Compared to the prior Uniform Assessment System (UAS) evaluation, it showed a decline in managing medication, phone use, bathing, personal hygiene, dressing, walking, locomotion, and toileting.

The proposed treatment is 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 conditions and is bedbound. She is appealing the denial of an increase in personal care services (per 15 minutes) to 70 hours per week. Uniform Assessment System (UAS) evaluation recently completed shows the patient requires maximal assistance to total dependence with all activities of daily living (ADLs). She is incontinent of bowel and bladder. Compared to the prior Uniform Assessment System (UAS) evaluation, it showed a decline in managing medication, phone use, bathing, personal hygiene, dressing, walking, locomotion, and toileting. The information provided shows that this patient has significant limitations in functioning that have progressed between Uniform Assessment System (UAS) evaluations. The approved personal care services 56 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living (ADLs). The proposed increase home care/personal care personal care services (per 15 minutes) to 70 hours per week is medically necessary.