Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Increase PCA Service for 24 Hours A Day (live in ) Per Diem, 7 Days A Week. 

The insurer denied the Increase PCA Service for 24 Hours A Day (live in ) Per Diem, 7 Days A Week. 

The denial is overturned. 

This male has conditions including dementia, diaries, hypertension, heart failure, arthritis, muscle weakness and incontinence.  He is appealing denial of increase PCA (personal care assistance) service for 24 hours per day, live in, 7 days per week.  He has been approved for partial increase PCA (personal care assistance) from 45.5 to 59.5 hours per week.  UAS (Uniform Assessment System) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, shopping, locomotion, and toilet use; maximal assistance with managing medications, bathing, dressing, walking, and toilet transfer; extensive assistance with managing finances, personal hygiene, and bed mobility; and independent with eating.  UAS (Uniform Assessment System) evaluation compared to the previous assessment shows decline in cognition, dressing, personal hygiene, toileting, bathing, walking and locomotion.  He uses a wheelchair and scooter indoors. He is incontinent of bowel and ladder. 

Appeal statement from New York State, notes the member requires assistance with ADLs (activities of daily living) due to advance age and multiple chronic conditions. Notes the member's status has declined in the last 90 days. 

Yes. The proposed treatment 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 ADLs (activities of daily living) including toileting, walking, transfers, turning/positioning, or feeding.  The member has several chronic conditions including dementia.  He is appealing denial of increase PCA (personal care assistance) service for 24 hours per day, live in, 7 days per week.  He has been approved for partial increase PCA (personal care assistance) from 45.5 to 59.5 hours per week.  Per UAS (uniform assessment system) evaluation completed, the member requires assistance with all ADLs (activities of daily living), except eating. UAS (uniform assessment system) evaluation compared to the previous assessment shows decline in cognition, dressing, personal hygiene, toileting, bathing, walking and locomotion.  He is incontinent of bowel and ladder.  The appeal statement notes there has been a decline in the member's functioning over the past several months. This member has significant cognitive and physical impairments that have progressed between UAS (personal care assistance) evaluations.  Other than eating, the member cannot function without assistance.  The approved 59.5 hours per week are inadequate to meet the member's needs for assistance with ADLs/IADLs (activities of daily living/Instrumental activities of daily living).  The proposed increase PCA (personal care assistance) service for 24 hours per day, live in, 7 days per week is medically necessary.