Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, arthritis, diabetes,
hypertension, COPD, and cardiac arrhythmia
Treatment: Increase Personal Care Service To 24 Hours A Day (live-in) 7 Days A Week. Total of 91 Hours Per Week
The insurer denied the Increase Personal Care Service To 24 Hours A Day (live-in) 7 Days A Week. Total of 91 Hours Per Week
The denial is overturned

The patient is female with conditions including Alzheimer's dementia, arthritis, diabetes, hypertension, COPD (chronic obstructive pulmonary disease), and cardiac arrhythmia. The patient's daughter is appealing denial of PCS (personal care services) 24 hours per day, live-in, 91 hours per week. She has been approved for 63 hours per week.

The patient lives alone. An appeal statement notes that the patient's daughter can no longer assist. UAS (Uniform Assessment System) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping and transportation; maximal assistance with bathing, dressing locomotion, stairs, toileting, managing medications, and phone use; and extensive assistance with eating. The patient's activity level is less than one hour. She is incontinent of bowel and bladder. Her daughter reports decline in cognitive status.

An appeal letter from the patient's attorney notes that the patient needs assistance with ADLs (activities of daily living), including unscheduled needs throughout the day and night. The letter notes the patient needs changing of diapers every two hours to avoid skin wounds.

A letter from the patient's PCP (primary care provider) states the patient has progressive worsening of cognitive impairment and needs assistance with all ADLs (activities of daily living). The letter notes that the patient wanders and needs around-the-clock healthcare assistance.

Yes, the Increase in Personal Care Service to 24 Hours A Day (live-in) 7 Days A Week, for a Total of 91 Hours Per Week is medically necessary.
Medically necessary services are those which are:
safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, and the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested health service is medically necessary, because it is consistent with generally accepted national standard of medical practice.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding.  Personal care service is necessary when assistance cannot be met from use of from informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.

The patient has cognitive impairment and mobility limitations.  This patient requires assistance with all ADLs/IADLs (activities of daily living/instrumental activities of daily living).  Her physical activity is less than one hour per day.  Appeal letters indicated deterioration in the patient's cognitive functioning and notes the patient needs assistance with all ADLs (activities of daily living) that occur throughout the day and night.  She is incontinent of bowel and bladder and noted to need diaper changes every two hours.  The patient has significant limitations with ADLs/IADLs (activities of daily living/instrumental activities of daily living).  This patient's limitations and need for extensive assistance total dependence with ADLs/IADLs (activities of daily living/instrumental activities of daily living), including assistance with toiling and frequent incontinence cannot be met with the approved 63 hours per week.  The requested 24-hour, live-in PCS (personal care service) is medically necessary.