202212-156570
2023
Healthfirst Inc.
Medicaid
Cardiac/ Circulatory Problems
Home Health Care
Medical necessity
Overturned
Case Summary
Diagnosis: Stroke, heart disease and dementia
Treatment: Personal care assistance services, a total of 134 hours per week
The insurer denied coverage for personal care assistance services, a total of 134 hours per week
The denial is overturned.
This is an elderly patient with a history of stroke, heart disease and dementia. The patient was living with the spouse in a private residence. The patient was a resident in a nursing facility at the time of the most recent assessment. The request is for Personal Care Assistance (PCA) services, a total of 134 hours per week.
The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as "Severely impaired." The patient is totally dependent for instrumental activities of daily living (IADL) including meal preparation, ordinary housework and managing finances. The patient requires maximal assistance for bathing, lower body dressing, ambulation and toilet transfer and use. The patient is incontinent of bowel and bladder. Extensive assistance is needed for upper body dressing, bed mobility and eating. The patient's severe cognitive status and limited functional ability are much the same as documented in the previous UAS report. However, after the more recent falls, hospitalization and current nursing facility length of stay, the patient's deconditioned status in addition to severe and progressive dementia, total dependence for IADL and extensive to maximal assistance for Activities of Daily Living (ADL) tasks, support the medical necessity of the requested 134 hours per week PCA services. Based on the enclosed documents reviewed, the patient's health and safety can be more appropriately provided and maintained by the requested PCA services, 134 hours per week; upon the patient's return home from the nursing facility.
Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care assistance services, a total of 134 hours per week is substantiated.