Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vascular dementia
Treatment: Increase Personal Care Services (24 hours a day,
7 days a week (split shift) For a Total of 168 Hours
The insurer denied Increase Personal Care Services (24 hours a day, 7 days a week (split shift) For a Total of 168 Hours.
The denial is upheld.

This patient is an elderly female with multiple medical conditions including vascular dementia, urinary incontinence, arthritis, heart failure, coronary artery disease. The request is for an increase in Personal Care Services (24 hours a day, 7 days a week (split shift) for a total of 168 Hours per week. A final adverse determination was issued 5 months ago, noting that supervision is not covered. The plan noted that an aide cannot prevent falls and injuries, and that the patient should make use of supplies and services offered, such as physical therapy, pressure reducing mattress, and easily removable clothing for toileting. 
The patient's daughter argues that "because of her medical 
conditions, my mother needs assistance to perform her activities of daily living, including to walk, toilet, transfer, turn and position throughout the night frequently and at unscheduled times." A nursing assessment dated 8 months ago notes that the patient requires maximal assistance for meal preparation, shopping, bathing, dressing the lower body, and toilet use. She is totally dependent for housework. She requires extensive assistance with managing her medications, personal hygiene, dressing the upper body, walking, and toilet transfer. An Aide Tasking Tool dated 8 months ago estimates that the total weekly time spent on addressing the patient's needs is 47 hours. The request for an increase in Personal Care Services to 168 hours per week, is under review. 

The requested health service of Increase Personal Care Services (24 hours a day, 7days a week (split shift) for a total of 168 hours is not considered medically necessary. 

The request is for an increase in Personal Care Services (24 hours a day, 7 days a week (split shift) for a total of 168 Hours per week from the currently approved 47 hours per week. 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. While the appeal materials indicate that the patient requires significant assistance for activities of daily living, time for housework, meal preparation, personal hygiene, shopping, toileting, bathing and dressing, these have already been accounted for in the 47 hours approved by the plan. The tasking tool from 8 months ago estimates that 47 hours are needed per week to meet this patient's needs, which is aligned with the currently approved hours. There is no documentation that the patient has significant wounds that require frequent turning and re-positioning at night, and there is no evidence why the patient cannot make use of a pressure reducing mattress. The patient is also noted to have equipment at home to assist with her activities of daily living and keep her safe, including grab bars, shower chair, personal emergency response system, incontinence supplies, and toilet. Notes from the patient's daughter and physician clearly indicate that additional hours are needed to maintain the patient's safety, including mitigating falls. However, personal care services are not covered for supervision and safety concerns, per New York State Guidelines. Based on the available information, the plan's initial denial rationale is appropriate, and 47 hours per week of Personal Care Services (PCS) are sufficient to meet the patient's needs. Thus, the requested increase in Personal Care Services (24 hours a day, 7days a week (split shift) for a Total of 168 Hours per week is not considered medically necessary.