Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease. 
Treatment: Personal Care Aide (PCA) services 12 hours per day, 7 days per week. 

The insurer denied: Personal Care Aide (PCA) services 12 hours per day, 7 days per week. 

The denial is overturned. 

The patient is an elderly female has medical conditions that include Alzheimer's disease, depression, hypertension, osteoarthritis of the knee, vertigo, gout, and back pain. She lives alone. Denial of personal care aide (PCA) services 12 hours per day, 7 days per week is being appealed. The health plan approved 7 hours per day, 7 days per week. The patient's Uniform Assessment System (UAS) evaluation completed 5 months ago shows independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances, bathing, and dressing; limited assistance with managing medications, phone use, personal hygiene, walking, locomotion, and toileting; and independent with bed mobility and eating. She has bowel and bladder incontinence. No fall in last 90 days is documented. UAS (Uniform Assessment System) evaluation completed last month shows a decline with housework and managing finances. 

Letters from the patient's provider note the patient has multiple medical conditions and impaired cognitive functioning and ambulatory ability. She has recurrent falls due to an unsteady gait. She has nighttime needs. She needs toilet use every one to two hours and repositioning every two hours. A letter from the patient notes that she lives alone and has no informal support. She reports falling when trying to ambulate without assistance. She needs help with ADLs (activities of daily living). 

The Personal Care Aide (PCA) services 12 hours per day, 7 days per week 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. Denial of personal care aide (PCA) services 12 hours per day, 7 days per week is being appealed. The health plan approved 7 hours per day, 7 days per week. The patient's UAS (Uniform Assessment System) evaluation completed 5 months ago shows the patient requires assistance with all ADLs (activities of daily living), except bed mobility and eating. She as bowel and bladder incontinence. UAS (Uniform Assessment System) evaluation completed last month shows a decline with housework and managing finances. Appeal statements note the patient needs assistance with ADLs (activities of daily living) and has mobility limitation resulting in falls. The provider is recommending frequent assistance with toileting and repositioning/turning. 
She has no informal assistance. The information provides shows that this patient has significant limitations in functioning. The approved PCA (personal care aide) 7 hours per day, 7 days per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested 12 hours per day, 7 days per week is medically necessary.