Appeal type: Medical necessity
Decision: Upheld

Diagnosis: CVA; Dementia. 
Treatment: Increase Personal Care Aide (PCA) Services Level 2: 10.5 hours per day - 7 day(s) per week for a total amount Of 73.5 hours per week. 

The insurer denied the Increase Personal Care Aide (PCA) Services Level 2: 10.5 hours per day - 7 day(s) per week for a total amount of 73.5 hours per week. 
The denial is upheld. 

The patient is a male. His medical conditions including history of CVA (cerebrovascular accident) and dementia.  He is approved for 52.5 PCA (personal care assistance), level 2, hours per week.  The patient is appealing denial of 73.5 PCA (personal care assistance), level 2, hours per week.  The daughter is appealing based on need for supervision and more assistance with medication, walking, toileting and meal prep. 

The patient's assessment performed shows moderately impaired cognition and functional status:  total dependence with meal prep, housework, and managing finances; maximal assistance with managing medications, phone use, bathing, personal hygiene, dressing, toilet use and eating; extensive assistance with walking, locomotion, toilet transfer and bed mobility.  He is frequently incontinent of bladder and occasionally incontinent of bowel.  The patient has support of spouse, daughter and son. His spouse pre-pours his medications and provides reminders to ensure compliance.  The patient has a cane, walker, wheelchair, incontinent supplies, and PERS (personal emergency response system). 

No, the proposed treatment is not medically necessary. 
Medically necessary services are those which are as follows: 
- safe 
- effective 
- generally accepted national standard of medical practice 
- not provided primarily for convenience of the patient or the practitioner 
- 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.  Withholding the increase in requested hours of services is not reasonably expected to affect the patient's health adversely. 

Level 2 personal care service is indicated for individuals that need assistance with housekeeping, cleaning, meal preparation, grocery shopping, and laundry as well as assistance with personal needs, including bathing, dressing, grooming, toileting, walking, feeding, assisting with administering medications, preparing meals with special diets, and routine skin care. This patient was approved for 52.5 PCA (personal care assistance) hours based on assessment performed. This assessment shows the patient needs assistance with meal prep, housework, managing finances, managing medications, phone use, bathing, personal hygiene, dressing, toilet use eating; extensive, walking, locomotion, toilet transfer and bed mobility. The patient is incontinent of bowel and bladder. The patient has a cane, walker, wheelchair, incontinent supplies, and PERS (personal emergency response system). The daughter has noted that that the patient needs supervision and more assistance with medication reminder, walking, toileting and meal prep. Assistance with medications, walking, toileting and meal prep has already been accounted for in the assessment. PCA (personal care assistance) services are not indicated for supervision or when there are no tasks being performed. The proposed increase in to a total 73.5 PCA (personal care assistance) hours per week is not medically necessary to meets this patient's need for assistance with ADLs (activities of daily living) and personal care as noted above. The approved 52.5 hours per week is sufficient.