Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia and stroke
Treatment: Increase Personal Care Services to 24 Hours a Day, 5 Days per Week (Live-In)
The insurer denied Increase Personal Care Services to 24 Hours a Day, 5 Days per Week (Live-In).
The denial is overturned.

This elderly male patient has medical conditions that include dementia and stroke with residual blindness. The denial of an increase in personal care services to 24 hours a day, 5 days per week (live-in) is being appealed. The health plan approved Personal Care Services (PCS) 6 hours a day, 5 days a week.
Uniform Assessment System (UAS) evaluation completed 3 months ago shows moderately impaired cognition and the patient requires assistance with all activities of daily living. The patient has bowel and bladder incontinence. Prior Uniform Assessment System evaluation performed 5 months ago shows the patient as independent with toilet use and bed mobility. He had one fall in the last 90 days. An appeal statement notes the patient needs assistance with all activities of daily living including nighttime toileting and diaper changes. He needs assistance with evening feeding. A letter from a Provider notes the patient's condition has declined since recent a hospitalization. He has weakness, loss of sight, dementia and is incontinent of urine. He has lost his eyesight and is confused when walking. He cannot use the commode without assistance. He currently has a private aide assisting with diapering and toileting. The aide gets up 2-3 times per night.

The requested increase in personal care services to 24 hours a day, 5 days per week (live-in) is medically necessary. 

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. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, walking, transfers, turning/positioning, or feeding. This patient has dementia and has had a recent stroke with residual blindness. The denial of an increase in personal care services to 24 hours a day, 5 days per week (live-in) is being appealed. 
The health plan approved personal care services 6 hours a day, 5 days a week. Uniform Assessment System (UAS) evaluation completed 3 months ago shows the patient requires assistance with all activities of daily living. The prior Uniform Assessment System evaluation performed 5 months ago shows the patient was independent with toilet use and bed mobility. He is incontinent of bowel and bladder. Appeal statements indicate that his condition has declined since a recent hospitalization and supports that he needs assistance with all activities of daily living. He needs frequent assistance with toileting. The information provided shows that this patient has significant limitations in functioning that have progressed since his stroke. The approved personal care services 6 hours a day, 5 days a week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 24 hours a day, 5 days per week (live-in), is medically necessary.