Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's Disease
Treatment: Increase Personal Care Aide (PCA) Level 2 Services For A Total Amount of 168 Hours Per Week, Pre-service
The insurer denied the Increase Personal Care Aide (PCA) Level 2 Services For A Total Amount of 168 Hours Per Week, Pre-service
The denial is upheld

The patient is a female with medical conditions including Alzheimer's disease. Denial of increase personal care aide (PCA) level 2 services for a total amount of 168 hours per week is being appealed. The patient has been approved for PCA (personal care aide) level 2: 12 hours/day - 5 day(s) per week with CDPAP (consumer directed personal assistance program): 4 hours/day -3 day(s) per week - 72 hours per week.

The patient lives alone in an apartment. The patient's son directs her care. Her son states that the patient's physical condition has declined and she is not safe alone. Uniform Assessment System (UAS) evaluation shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, lower body dressing, toilet use, and bathing; extensive assistance with phone use, personal hygiene, bed mobility, eating, and upper body dressing; and limited assistance with walking, locomotion, and toilet transfer. She has frequent bladder incontinence and infrequent bowel incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with personal hygiene, lower body dressing, toilet use, bed mobility, and eating. She has a cane, walker, shower chair, shower grab bar, interior safety cameras, and pull-ups.

An appeal letter from the patient's doctor notes the patient has multiple conditions that have been rapidly deteriorating. Notes she needs help with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation. Notes the patient needs assistance at night due to wandering and falls.

An appeal letter from another provider notes the patient has progressive dementia. Notes she needs constant supervision due to nighttime wandering.

No, the requested increase in personal care aide services to 168 hours/week is not 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 is an appeal for denial of denial of increase personal care aide (PCA) level 2 services for a total amount of 168 hours per week. The patient has been approved for PCA (personal care aide) level 2: 12 hours/day - 5 day(s) per week with CDPAP (consumer directed personal assistance program): 4 hours/day -3 day(s) per week - 72 hours per week.

This patient has progressive Alzheimer's dementia. UAS (Uniform Assessment System) evaluation completed shows she needs assistance with all ADLs (activities of daily living). Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with personal hygiene, lower body dressing, toilet use, bed mobility, and eating. Appeal statements note that the patient has deterioration in physical functioning and progressive dementia resulting in need for constant supervision. It is noted that the patient wanders at nighttime. PCA (personal care aide) is not indicated for supervision or when no tasks are being performed. The reports provided show the patient needs nighttime safety supervision but do not support that the patient has need for nighttime tasks. The approved PCA (personal care aide) level 2: 12 hours/day - 5 day(s) per week with CDPAP (consumer directed personal assistance program): 4 hours/day -3 day(s) per week - 72 hours per week is appropriate to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed PCA (personal care aide) level 2 services for a total amount of 168 hours per week is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.