Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's and arthritis
Treatment: Increase Personal Care Aide Services Level II: 12 Hours per Day, 7 Days per Week, Total of 84 Hours per Week
The insurer denied the Increase Personal Care Aide Services Level II: 12 Hours per Day, 7 Days per Week, Total of 84 Hours per Week.
The denial is upheld. 

This female with medical conditions including Alzheimer's and arthritis with symptoms of confusion and weakness and requires assistance with weight bearing.  She is appealing denial of increase in personal care aide (PCA) services to 84 hours per week.  She has been approved for 42 hours per week, which has been effective for the last 5 months.  

The patient is currently living in a Nursing and Rehabilitation facility.  Her daughter is supportive and provides assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), medications, walking and eating, 24 hours per day.  Assessment performed shows cognition moderately impaired and functional status: total dependence with meal preparation, housework, managing finances, and transportation; maximal assistance with managing medications, bathing, and lower body dressing; extensive assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, toileting, and eating; and limited assistance with bed mobility.  Compared to assessment performed previously, the patient has increased needs with upper body dressing and eating.  She has urinary incontinence and wears diapers.  She has a cane, walker, shower chair, and shower grab bar.  A letter from the patient's provider states the patient is bed bound and has multiple conditions including dementia.  The letter states her mental status is declining; she needs assistance with ADLs and IADLs; she has urinary incontinence and requires repositioning every two hours to avoid skin breakdown.  The letter states the patient cannot be left unattended for an extended period of time.  A letter from another provider states the patient would benefit from increase in hours of home health aide (HHA) services.  The patient has decreased mobility, hallucinations, and wanders around.  Handwritten note indicates need for 24 hour HHA.

No, the proposed treatment, increase in personal care aide (PCA), 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 ADLs, health maintenance activities, and routine support services.  This patient is appealing denial of 84 PCA hours per week.  The patient has been approved for ongoing 42 PCA hours per week based on assessment performed previously.  The patient has Alzheimer's and limited mobility, resulting in need for some level of assistance with all ADLs and IADLs.  She receives support from her daughter.  The previous assessment compared to the recent assessment shows increased needs with upper body dressing and eating.  Otherwise, it shows no significant change in cognition or functional status.  The letter from the patient's provider states the patient is bed bound and needs repositioning every two hours.  However, this statement is not supported by either assessment or letters from other providers.  Appeal letters opine that the patient needs additional PCA hours due to cognitive impairment prohibiting her being left alone.  Personal care services (PCS) are not indicated for supervision.  The approved 42 hours per week is sufficient to meet this patient's needs for assistance with ADLs and personal care.  Personal care services are not indicated when there are no tasks being performed.  The proposed increase in PCA to a total of 84 hours per week is not medically necessary.