Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, diabetes mellitus (DM), depression, and bowel/bladder incontinence.
Treatment: Increase Personal Care Worker (PCW) Services 7 Days Per Week, 7 Hour Per Day, 49 Hours Per Week To PCW Services 7 Days Per Week, 8 Hours Per Day, 56 Hours Per Week
The insurer denied the Increase Personal Care Worker (PCW) Services 7 Days Per Week, 7 Hour Per Day, 49 Hours Per Week To PCW Services 7 Days Per Week, 8 Hours Per Day, 56 Hours Per Week.
The denial is upheld. 

This patient is an male with diagnoses including dementia, diabetes mellitus (DM), depression, and bowel/bladder incontinence.  The patient lives with spouse in one bedroom apartment on ground floor.  The patient is appealing requested 56 personal care worker (PCW) hours from 49 hours.  Assessment performed shows moderately impaired cognitive skills and functional status: maximal assistance with bathing and lower body dressing, extensive assistance with upper body dressing and toileting, and limited assistance with locomotion and eating.  The patient has a rolling walker, bedside commode and a personal emergency response system (PERS).  The patient's daughter prepares medications on a weekly basis.  The patient is able to self administer medications.  The daughter reports the patient requires contact guard assist (CGA) with ambulation and weight bearing assistance with transfers.  The patient had a history of wandering outdoors but it has not happened in a long time.  Appeal letter from the daughter states the patient has fallen two times in the past years when attempting to walk to the bathroom.  He has difficulty getting out of bed, walking to the bathroom and using the bathroom. He requires regular diaper changes.  He requires frequent bathroom visits due to medications.  

Appeal letter from medical provider states the patient's condition has worsened.  The patient is frequently incontinent and has difficulty transferring due to hip arthritis.  Also, it is noted that the patient is a high fall risk.  The provider recommends care 12 hours per day, 7 days per week.  Prior letters from provider recommend 12 hour daily care.

No, the proposed treatment 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 activities of daily living (ADLs), health maintenance activities, and routine support services.  This patient was approved for 49 hours based on assessment.  This assessment shows the patient needs maximal assistance with bathing, dressing, toileting, locomotion and eating.  The patient has a rolling walker and bedside commode.  The patient is appealing the number of hours approved primarily based on need for assistance with transfers and toileting, which is already accounted in the assessment.  The doctor is recommending additional hours due to progression of the patient's condition.  This was addressed in the assessment.  The approved 49 hours per week is sufficient to provide assistance with ADLs and personal care, as noted above.  Seven hours per day is sufficient to meet this patient's needs as noted above.  PCW is not indicated when there are no tasks being performed.  PCW is not indicated for supervision.  The proposed increase in PCW to a total of 56 hours per week is not medically necessary to meet this patient's need for assistance with ADLs and personal care.