Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia. 
Treatment: Increase in Personal Care Aide (PCA) Services for a Total Amount of 168 Hours Per Week. 

The insurer denied the Increase in Personal Care Aide (PCA) Services for a Total Amount of 168 Hours Per Week. 

The denial is upheld. 

This female patient has conditions including dementia. She lives alone. She is appealing denial of increase in personal care aide (PCA) services for a total amount of 168 hours per week.  The health plan approved 42 hours per week. 

Uniform Assessment System (UAS) evaluation performed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, locomotion, and toilet use; maximal assistance with managing medications, phone use, bathing, personal hygiene, dressing, walking, and toilet transfer; extensive assistance with bed mobility; and supervision with eating. The UAS notes the patient needs cues at all times. She has frequent bladder incontinence and occasional bowel incontinence. She has no falls. Comparison of Uniform Assessment System (UAS) evaluations performed, there has been a progress in cognition to moderately impaired, dressing to maximal assistance, toilet use to total assistance, toilet transfer to maximal assistance, walking to maximal assistance, locomotion to total assistance, eating to supervision, and bed mobility to extensive assistance.  The patient is noted to be forgetful and forgets to eat. 

An appeal statement from New York indicates the patient's health is declining and the approved personal care aide (PCA) 42 hours per week does not meet needs for assistance with eating, transferring, and toileting. The patient's daughter notes that the patient is unable to perceive time of day, wakes up in the middle of the night and walks to the kitchen or bathroom, and is at risk of falling. 
A letter from the provider notes the patient has become increasingly dependent and requires more assistance in order to stay in her home. 

No, the proposed Increase in Personal Care Aide (PCA) Services for a Total Amount of 168 Hours Per 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 patient has progressive dementia. She is appealing denial of increase in personal care aide (PCA) services for a total amount of 168 hours per week. The health plan approved 42 hours per week. Uniform Assessment System (UAS) evaluation performed shows the patient requires assistance with all activities of daily living (ADLs), except eating. She requires cueing. She has bowel and bladder incontinence. Comparison of Uniform Assessment System (UAS) evaluations performed, there has been a progress in cognition to moderately impaired, dressing to maximal assistance, toilet use to total assistance, toilet transfer to maximal assistance, walking to maximal assistance, locomotion to total assistance, eating to supervision, and bed mobility to extensive assistance. An appeal statement indicated that the patient has deteriorating health due to cognition and weakness. She does not perceive time-of-day and gets up at night to go the kitchen and/or bathroom. Her provider notes that she needs more assistance in order to stay in her home. 

The information provided indicates that the patient needs supervision. Personal care aide (PCA) services are not indicated for supervision or when no tasks are being performed. The approved personal care aide (PCA) 42 hours per week is appropriate and medically indicated to meet the patient's needs for assistance with activities of daily living (ADLs) and personal care. The proposed increase in personal care aide (PCA) services to total 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.