Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's dementia, depression and diabetes. 
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 56 Hour(s) per Week. 

The insurer denied the Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 56 Hour(s) per week. 

The denial is upheld. 

The patient is a female. Her medical conditions include Alzheimer's dementia, depression and diabetes. Denial of increase in Personal Care Services to 56 hours per week is being appealed. She has been approved for 35 hours per week. 

UAS (Uniform Assessment System) evaluation completed shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing medications, phone use, and bathing; limited assistance with dressing and toilet use; supervision with walking, locomotion, toilet transfer and eating; and independent with bed mobility. The patient has occasional bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been an improvement in ability to perform housework, manage finances, shopping, walking, locomotion, and toilet transfer; and a decline with ability to perform phone use. 

An appeal letter from the patient's provider notes the patient has memory impairment, chronic headache and hypertension. It is noted the patient is disabled and her cognitive function has deteriorated in the last 6 months. It is noted the patient needs 12 hour per day home attendant service. 

An appeal letter from another provider notes the patient often gets confused and has psychotic episodes. She is unable to function independently and maintain basic ADLs (activities of daily living). 

No, the Personal Care Services 56 Hours per Week is not medically necessary. 
Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase in Personal Care Services to 56 hours per week is being appealed. She has been approved for 35 hours per week. 

This patient has conditions including Alzheimer's dementia. UAS (Uniform Assessment System) evaluation completed shows the patient needs assistance with meal preparation, housework, shopping, managing medications, phone use, bathing, dressing and toilet use. Assistance is not need with walking, locomotion, toilet transfer eating, and bed mobility. There has been no significant decline in physical functioning compared to UAS (Uniform Assessment System) evaluation completed previously. Appeal statements indicate that the patient has deteriorating cognitive functioning with confusion and episodes of psychosis. PCS (personal care service) is not indicated for supervision or when no tasks are being performed. The approved PCS (personal care service) 35 hours per week is appropriate and medically necessary to meets the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase in PCS (personal care service) to total 56 hours per week is not medically necessary. 

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