Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, macular degeneration, stress incontinence and osteoarthritis.
Treatment: Increase in Personal Care Aide Hours To 7 Days x 12 Hours.
The insurer denied the Increase in Personal Care Aide Hours To 7 Days x 12 Hours.
The denial is upheld.

The patient is a female with conditions including dementia, macular degeneration, stress incontinence and osteoarthritis (OA).  She has wrist and hands deformity.  She requires rollator for ambulation.  She is appealing denial of increase in personal care assistance (PCA) hours to 7 Days x 12 hours. She has been approved for personal care assistance (PCA) 4 days x 10 hours and 3 days x 11 hours.  

The patient lives with her spouse in a one bedroom apartment.  Assessment performed shows the patient with moderately impaired cognition and functional status:  total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, stairs, and transportation; extensive assistance with phone use, bathing, dressing, locomotion, and toileting; limited assistance with bed mobility; and eating; and supervision with personal hygiene.  She is frequently incontinent.  Appeal letter the provider states the patient has significant physical and cognitive decline.  The letter states the patient requires oral assistance with her activities of daily living (ADLs) and is a high fall risk.  Appeal letter another provider states the patient has rapidly deteriorating mental state and physical health.  It states the patient is legally blind, immobile and bed confined.  It states she has debilitating conditions.  It states she requires assistance with activities of daily living (ADLs), continuous supervision, assistance with activities of daily living (ADLs), day and nighttime change of soiled diapers, and bi-hourly turning and repositioning.

No, the proposed treatment is not medically necessary.
Medically necessary services are those which are: 1) safe. 2) effective. 3) generally accepted national standard of medical practice. 4) not provided primarily for convenience of the patient or the practitioner. 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is not medically necessary because it is not consistent with generally accepted national standard of medical practice.

Personal Care 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 personal care assistance (PCA) services, 12 hours per day.  

The assessment performed shows the patient has moderately impaired cognition and needs assistance with meal preparation, housework, managing finances, shopping, managing medications, stairs, transportation, phone use, bathing, dressing, locomotion, toileting, bed mobility, and eating.  Appeal letters from providers note decline in the patient's cognitive and physical functioning.  The letters indicate the patient needs total assistance and is bedbound.  However, the assessment performed show the patient does not require total assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs) nor that the patient is confined to the bed.  The assessment shows the patient requires limited assistance with bed mobility.  This assessment shows no significant change from prior assessment performed two months prior.  The approved personal care assistance (PCA) four days for ten hours and three days for eleven hours is sufficient to provide assistance with activities of daily (ADLs) and personal care as noted above.  Personal care services (PCS) are not indicated for management of chronic medical conditions.  Personal care services (PCS) are not indicated when there are no tasks being performed.  The proposed increase in personal care services (PCS) to a total of 12 hours per day is not medically necessary to meets this patient's need for assistance with activities of daily living (ADLs) and personal care.