Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, repeated falls, stress incontinence, abnormal gait, and dizziness.
Treatment: Increase Personal Care Services to 77 hours per week.
The insurer denied the Increase Personal Care Services to 77 hours per week.
The denial is overturned.

The patient is a male. He has multiple conditions including dementia, repeated falls, stress incontinence, abnormal gait, and dizziness.  This is an appeal of denial of PCS (personal care services) 77 hours per week.  He has been approved for 42 hours per week.  He lives with his wife who has limited abilities.

UAS (Uniform Assessment System) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework managing finances and medications, and shopping; maximal assistance with phone use; extensive assistance with bathing, and lower body dressings limited assistance with personal hygiene, upper body dressing, toileting, bed mobility; and supervision with walking and locomotion and eating.  He is frequently incontinent of bowel and bladder.  The patient's DME (durable medical equipment) includes grab bar pending installation, shower chair, wheelchair, pull ups and bedside rail.  UAS (Uniform Assessment System) evaluation completed last year shows a decline in the patient's ability to manage medications and finances, phone use, lower body dressing and bed mobility.

An appeal letter from the family notes that the patient had a decline in ability to communicate over the past year, he requires two-person assistance to get in and out of bed, and he is no longer able to shower, dress, and perform personal hygiene.  He is no longer continent.  It further notes his cognition has also declined since last year.  The patient was recently hospitalized.

Yes, the increase in personal care services to 77 hours/week is medically necessary.
Medically necessary services are those which are:
-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 requested health service is medically necessary, because it is 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 medical conditions including dementia.  This is an appeal for denial of PCS (personal care services) 77 hours per week.  The patient has been approved for 42 hours per week.

The UAS (Uniform Assessment System) evaluation completed last year shows the patient requires assistance with all ADLs/IADLs (activities of daily living/instrumental activities of daily living), except walking/locomotion and eating.  Compared to the UAS (Uniform Assessment System) evaluation completed earlier this year, there has been a deterioration in functional status with managing medications and finances, phone use, lower body dressing and bed mobility.  The appeal letter from the family indicated that there has been significant decline in the patient's cognitive and functional status since last year.  The patient is no longer able to communicate and requires two-person assist to get, in and out of bed.  He was hospitalized recently.  There has been significant decline in cognition and functional status since last year.  He requires significant assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living).  The approved PCS (personal care services) 42 hours per week are inadequate to meet the patient's needs with ADLs (activities of daily living) and IADLs (instrumental activities of daily living) as noted above.  The proposed increase PCS (personal care services) to 77 hours per week is medically necessary.