Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypertension, hyperlipidemia, osteoarthritis
Treatment: Personal Care Worker Service 13 Hours per Day Live-in, 7 Days per Week, Total 91 Hours per Week
The insurer denied the personal care worker service 13 hours per day live-in, 7 days per week, total 91 hours per week.
The denial is overturned. 

This female has conditions including dementia, hypertension, hyperlipidemia, osteoarthritis, osteopenia, overactive bladder, chronic constipation, asthma, and chronic back pain and hip pain.  This is an appeal for denial of personal care services (PCS) 13 hours per day live-in, seven days per week, 91 hours per week.  The patient has been approved for personal care services (PCS) 13 hours per day live-in, five days per week and 12 hours per day, two days per week, total 89 hours per week.  

The patient lives alone.  She has informal support of family members after service hours.  Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, phone use, bathing, personal hygiene, dressing, and toilet use; limited assistance with walking, locomotion, and toilet transfer; and independent with bed mobility and eating.  She performs physical activity three to four hours.  She is frequently incontinent of bladder.  She uses a wheelchair for ambulation.  

Neuropsychological evaluation and several appeal letters are provided.  Neuropsychological evaluation shows significant decline in cognitive functioning.  The appeal letters show the patient has progressive Alzheimer's dementia and requires patient assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs).  She has been hospitalized twice after a fall and syncope.  She has been found on the floor after falls and needs more supervision.  Overnight assistance is recommended.

Yes, the proposed treatment is medically necessary.

The proposed treatment is medically necessary because it is 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 has multiple chronic medical conditions.  She is appealing denial of personal care services (PCS) 13 hours per day live-in, seven days per week, 91 hours per week.  She has been approved for personal care services (PCS) 13 hours per day live-in, five days per week and 12 hours per day, two days per week, total 89 hours per week.  

The patient lives alone and has family for informal support.  Uniform Assessment System (UAS) evaluation completed shows the patient needs assistance with meal preparation, housework, shopping, managing finances and medications, phone use, bathing, personal hygiene, dressing, toilet use, walking, and locomotion.  She is incontinent of bladder.  Neuropsychological evaluation shows significant decline in cognitive functioning.  The patient has had falls and has been hospitalized twice after a fall.  Based on the progression of this patient's cognitive decline, the proposed personal care services (PCS) 13 hours per day live-in, seven days per week, 91 hours per week are medically necessary.