Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Early onset Alzheimer's dementia, COPD, breast cancer, and urinary incontinence
Treatment: Increase Personal Care Services to 24 hours/day, 7 days/week (live-in), for a total of 91 hours/week
The insurer denied the increase in personal care services to 24 hours/day, 7 days/week (live-in), for a total of 91 hours/week.
The denial is upheld.

The patient is a female with conditions including early onset Alzheimer's dementia, COPD (chronic obstructive pulmonary disease), breast cancer, and urinary incontinence. This is an appeal of denial of 24 per day, live in PCS (personal care service). She has been approved for 56 hours per week. She has children and grandchildren that visit. Her son reports the patient hallucinates at night and needs overnight hours.

UAS (Uniform Assessment System) evaluation performed shows modified independent cognitive skills and functional status: maximal assistance with housework and shopping, extensive assistance with meal preparation, managing finances and medications, and bathing, limited assistance with phone use, personal hygiene, dressing, walking, locomotion, and toileting, and independent with bed mobility and eating. She ambulates without an assistive device. She is frequently incontinent of bladder and infrequently incontinent of bowel.

A letter from the patient's physician notes the patient has auditory and visual hallucinations and requires support and redirection throughout the day and night. The physician further notes that the patient needs moderate to maximal assistance with 24 hour live-in home care services.

No, the increase in personal care services to 24 hours/day, 7 days/week (live-in), for a total of 91 hours/week is not medically necessary.

Medically necessary services are those which are: 1) safe 2) effective 3) generally accepted national standard of medical practice 4) not provided primarily for convenience of the patient or the practitioner 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested health service is not medically necessary because it is not consistent with generally accepted national standard of medical practice.

Personal Care 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 multiple chronic conditions, including early-onset Alzheimer's dementia. The denial of 24 hour, live-in PCS (personal care service) is being appealed.

The patient was approved for 56 PCS (personal care service) hours per week based on UAS (Uniform Assessment System) evaluation performed. This assessment shows the patient needs extensive to maximal assistance with housework, shopping, meal preparation, managing finances and medications, and bathing. She requires limited assistance with phone use, personal hygiene, dressing, walking, locomotion, and toileting. She is independent with bed mobility and eating. She has informal support of her children and grandchildren. She has a cane, but she does not have other assistive equipment. The plan has recommended PT (physical therapy) and equipment to assist with showering and toileting.

The patient's son and provider are requesting 24 hours, live-in PCS (personal care service) because the patient needs nighttime support with redirection. PCS (personal care service) is not indicated for supervision or when there are no tasks being performed. The information provided does not support an increase to 24 hours, live-in PCS (personal care service). The patient has family support. Assistive equipment can be provided to improve functional status without the aide. The proposed increase in PCS (personal care service) to 24 hours, live-in is not medically necessary to meets this patient's need for assistance with ADLs (activities of daily living) and personal care.