Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's dementia, diabetes.
Treatment: Increase Personal Care HHC Level II per 15 Minutes to 24 Hours per Day (Live-In).
The insurer denied: Increase Personal Care HHC Level II per 15 Minutes to 24 Hours per Day (Live-In).
The denial is upheld.

This elderly male patient has conditions including Alzheimer's dementia, diabetes, hypertension, osteoarthritis, and colon cancer. He lives alone. He is appealing the denial of an increase in personal care to 24 hours per day (live in). The health plan approved personal care of 84 hours per week.
Uniform Assessment System (UAS) evaluation completed on recently shows the patient has minimally impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing finances and medications, stairs, transportation, bathing, and dressing; extensive assistance with phone use, personal hygiene, walking, locomotion, toileting, and bed mobility; and supervision with eating. He has occasional bowel and bladder incontinence. Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline in functioning with upper body dressing.
A letter from the Provider notes the patient has frequent episodes of confusion and poor sleeping. He has a phobia of being left alone. A letter from another Provider notes the patient's mental status has deteriorated as well as physical condition. The patient needs home care services and supervision during day and night. A letter from a third Provider notes the patient needs 24-hour assistance with activities of daily living due to neurological conditions. A letter from a fourth Provider notes the patient needs constant care due to medical conditions.

The proposed treatment is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, walking, transfers, turning/positioning, or feeding. This patient has multiple chronic medical conditions. He is appealing denial of increase in personal care to 24 hours per day (live in). The health plan approved personal care of 84 hours per week. Uniform Assessment System (UAS) evaluation completed recently shows the patient needs assistance with all activities of daily living, except eating. Compared to Uniform 
Assessment System (UAS) evaluation completed last year, there has been a decline in functioning with upper body dressing. Appeal statements support the patient has several chronic conditions. He is noted to have confusion and phobia of being left alone. Additional care is recommended for assistance with activities of daily living and supervision during the day and night. However, the information provided does not support tasks being performed that require 24-hour care. There has been no significant change in the patient's functional status from last year's assessment to this year's assessment. The information does not support that the patient has nighttime needs that require an aide. Personal care is not indicated for management of chronic medical conditions or for supervision. The increase in in personal care to 24 hours per day (live in) is not medically necessary. Continuation of the approved personal care at 84 hours per week is appropriate for this patient.