Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, hypertension, abnormal gait, diabetes,and ASCVD (atherosclerotic cardiovascular disease).
Treatment: Increase Personal Care Services To 24 Hours A Day, Seven Days per Week (Live -In) for a Total of 91 Hours per Week.
The insurer denied the Increase Personal Care Services To 24 Hours A Day, Seven Days per Week (Live -In) for a Total of 91 Hours per Week.
The denial is upheld.

This male has medical conditions including dementia, hypertension, abnormal gait, diabetes, and atherosclerotic cardiovascular disease (ASCVD).  He resides in a Nursing and Rehabilitation facility.  The facility provides 24-hour housekeeping and laundry services.  He is appealing denial of Personal Care Services to 24 hours a day, seven days a week, live-in for a total of 91 hours a week.  The plan approved personal care services eight hours a day, five days a week and seven hours a day, two days a week for a total of 54 hours a week.  

Uniform Assessment System (UAS) evaluation completed shows the patient needs assistance with meal preparation, housekeeping, shopping, bathing, dressing, toileting, walking, and personal hygiene.  He needs limited help with bed mobility and eating.  He has bladder and bowel incontinence.  The patient has a walker for mobility.  An appeal letter from the provider notes the patient has advancing dementia and experiences frequent loss of balance.  It notes the patient requires assistance with activities of daily living (ADLs) as accounted for in the Uniform Assessment System (UAS) evaluation.  A letter from another provider recommends 24 hours assistance.  A letter from the patient's son notes the patient has decline in health.  It notes the patient needs more assistance with activities of daily living (ADLs) during the day and night, including assistance with incontinence.

No, the proposed treatment is not medically necessary.
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.  The patient has several chronic conditions including dementia, hypertension, abnormal gait, diabetes, and atherosclerotic cardiovascular disease (ASCVD).  He is appealing denial of Personal Care Services to 24 hours a day, seven days a week, live-in for a total of 91 hours a week.  The plan approved personal care services eight hours a day, five days a week and seven hours a day, two days a week for a total of 54 hours a week.  

Unfiorm Assessment System (UAS) evaluation completed shows the patient needs assistance with meal preparation, housekeeping, shopping, bathing, dressing, toileting, walking, and personal hygiene.  He needs limited help with bed mobility and eating.  He has bladder and bowel incontinence.  Appeal statements note the patient has advancing dementia, imbalance and multiple chronic conditions with decline in health.  Personal care services are not indicated when no tasks are being performed or for supervision with safety.  The documentation provided does not support that this patient has needs for 24-hour care, such as frequent turning/repositioning or toileting.  The approved personal care services 54 hours per week is adequate to meet the patient's needs for assistance with activities of daily living (ADLs)/instrumental activities of daily living (IADLs).  The proposed increase in personal care services to 24 hours a day, seven days a week, live-in, is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.