Diagnosis: Right knee replacement, coronary artery disease, cancer, depression, anxiety, and diabetes.
Treatment: Increase Personal Care Assistance (PCA) Services to 42 Hours per Week.
The insurer denied: Increase Personal Care Assistance (PCA) Services to 42 Hours per Week.

The denial is overturned.

This patient is an elderly female who has conditions including right knee replacement, coronary artery disease, cancer, depression, anxiety, and diabetes. She is appealing denial of an increase personal care assistance (PCA) services from 36 to 42 hours per week.

Uniform Assessment System (UAS) evaluation completed recently shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, shopping, bathing, and dressing; limited assistance with personal hygiene, walking, locomotion, and toileting; and independent with bed mobility and eating. She does not have incontinence.

Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with shopping and toilet use.

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 is appealing the denial of an increase in personal care assistance (PCA) services from 36 to 42 hours per week. Uniform Assessment System (UAS) evaluation completed recently shows the patient is independent with bed mobility and eating. Otherwise, she requires assistance with activities of daily living (ADLs). Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with shopping and toilet use. This patient requires assistance with meal preparation, housework, shopping, managing finances and medications, shopping, bathing, dressing personal hygiene, walking, locomotion, and toileting. The required assistance with activities of daily living (ADLs) and decline in the patient's level of functioning between Uniform Assessment System (UAS) evaluations, supports the proposed increase in personal care assistance (PCA) services. The approved personal care assistance (PCA) 36 hours per week is inadequate to meet this patient's needs for assistance with activities of daily living (ADLs). The proposed increase in personal care assistance (PCA) services to 42 hours per week is medically necessary.