Diagnosis: Malignant pleural effusion
Treatment: Personal Care Aide (PCA) Level II Live-in Per Diem, 7 Days per Week - for a Total of 7 Days per Week
The insurer denied: Personal Care Aide (PCA) Level II Live-in Per Diem, 7 Days per Week - for a Total of 7 Days per Week
The denial is overturned.

This elderly female patient has a malignant pleural effusion secondary to lymphoma, congestive heart failure, osteoarthritis, cervical and lumbar radiculopathy, diabetic retinopathy, macular edema, and insomnia. The patient lives alone. Denial of personal care aide (PCA) live-in, 7 days per week is being appealed. The health plan approved 7 hours per day, 7 days per week for a total of 49 hours per week. A letter from her Provider notes the patient is unable to perform activities of daily living (ADLs) due to her multiple medical problems. Aide logs show the patient receiving frequent assistance with activities of daily living 24 hours per day.

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. The denial of personal care aide (PCA) live-in, 7 days per week is being appealed. The health plan approved 7 hours per day, 7 days per week, for a total of 49 hours per week. Appeal statements note the patient lives alone and needs additional assistance with activities of daily living. Aide logs support the patient's needs for frequent assistance around-the-clock with activities of daily living. The patient lives alone and does not have informal support. The information provided show that this patient has significant limitations in functioning. The approved personal care aide 49 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to
live-in is medically necessary.