Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, ischemic cardiomyopathy, hypertension, heart failure, diabetes mellitus with neuropathy, chronic kidney disease, etc.
Treatment: Increase Personal Aide Hours to 7 Days per Week, 8 Hours per Day - a Total of 56 Hours per Week
The insurer denied the Increase Personal Aide Hours to 7 Days per Week, 8 Hours per Day - a Total of 56 Hours per Week
The denial is upheld. 

This male has conditions including dementia, ischemic cardiomyopathy, hypertension (HTN), heart failure, diabetes mellitus (DM) with neuropathy, chronic kidney disease (CKD), chronic obstructive sleep apnea (COPD), orthostatic hypotension, and cerebral vascular accident (CVA) with residual right sided hemiparesis.  He is appealing denial of 56 personal care aide (PCA) hours per week.  He has been approved for 35 hours per week.  He lives alone in one bedroom apartment  Assessment performed shows modified independent cognition and functional status: total dependence with housework; maximal dependence with meal preparation, and shopping; extensive assistance with managing medications and finances, transportation, bathing, and lower body dressing; limited assistance with phone use, upper body dressing, walking, locomotion, toileting; and independent with personal hygiene, bed mobility and eating.  He was observed transferring from sit to stand unassisted, with walker.  Durable medical equipment (DME) includes rollator, shower chair, cane, and show grab bars. The patient had a fall but was able to get up on his own.  Assessment shows no significant change compared several months prior.  

The letter from the patient's provider states the patient has rapidly deteriorating mental and physical health and functional status.  Notes he has decreased verbal communication and vascular dementia with paranoia.  He has limited mobility due to pain and requires assistance of an aide and walker.  Notes he needs assistance with activities of daily living (ADLs) 12 hours per day.

No, the proposed increase in PCA hours was 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 proposed treatment 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 is appealing denial of 56 personal care aide (PCA) hours per week, He was approved for 35 hours per week.  Assessment performed shows the patient needs assistance with housework, meal preparation, shopping, managing medications and finances, transportation, bathing, dressing, phone use, upper body dressing, walking, locomotion, and toileting.  He is independent with personal hygiene, bed mobility and eating.  During this assessment, the patient was observed to transfer from sit to stand with use of walker only.  He has durable medical equipment (DME) to assist with performing activities of daily living (ADLs).  

The appeal letter from his doctor notes the patient has deteriorating mental and physical functioning and requires assistance of aide and walker with ambulation.  However, these statements are not supported by the assessments as the recent assessment did not show significant change from that performed previously and the patient was observed to transfer and ambulate without need of assistance from an aide.  The approved 35 hours per week is sufficient to provide assistance with activities of daily living (ADLs) and personal care as noted above. 

Personal care aide (PCS) services are not indicated for management of chronic medical conditions.  Personal care aide (PCA) is not appropriate when there are no tasks being performed.  The proposed increase in Personal care aide (PCA) to a total 56 per week is not medically necessary to meets this patient's need for assistance with Personal care aide (ADLs) and personal care.