Appeal type: Medical necessity
Decision: Upheld

Diagnosis: arthritis, status post CVA (cerebrovascular accident), dementia, hypertension, CAD (coronary artery disease), orthostatic hypotension, diabetes, impaired vision and hearing loss
Treatment: Increase Home Care/Personal Care Level 2 Personal Care Services, per 15 minutes Increase To 24 Hours Per Day (live-in)
The insurer denied the Increase Home Care/Personal Care Level 2 Personal Care Services, per 15 minutes Increase To 24 Hours Per Day (live-in)
The denial is upheld. 

The patient is a male. His medical conditions include arthritis, status post CVA (cerebrovascular accident), dementia, hypertension, CAD (coronary artery disease), orthostatic hypotension, diabetes, impaired vision and hearing loss.  Denial of increase Personal Care Services 24 hours per day, live-in, is being appealed.  He has been approved for 56 hours per week.

UAS (Uniform Assessment System) evaluation completed notes the patient has minimally impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with stairs, and transportation; extensive assistance with managing finances and mediation, bathing, and lower body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toileting; and independent with bed mobility and eating.  He occasionally has bladder incontinence.  Compared for UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in cognition and functional status with walking and locomotion, and there was an improvement in bed mobility, toileting, and personal hygiene.

An appeal statement notes the patient has multiple chronic conditions and an unsteady gait. It notes the patient needs 24 hour care for safety.  An appeal letter notes the patient has rapidly deteriorating mental and physical status. It notes the patient has dementia and progressive amnesia and disorientation. He has difficulty ambulating. He has repeated falls, mostly at nighttime when unsupervised. He requires day and nighttime assistance with diaper changes. It notes the patient needs 24 hour per day assistance to maintain current health and provide supervision and assistance.  An appeal statement notes the patient needs assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation.

No, the increase in personal care to 24 hours/day, live in, is not 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. Denial of increase Personal Care Services to 24 hours per day, live-in, is being appealed. He has been approved for 56 hours per week.

This patient has multiple chronic conditions including dementia. The UAS (Uniform Assessment System) evaluation completed most recently shows the patient needs assistance with meal preparation, housework, and shopping; maximal assistance with stairs, and transportation; extensive assistance with managing finances and mediation, bathing, and lower body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toileting. He has occasional bladder incontinence. Compared for UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in cognition and functional status with walking and locomotion; and there was an improvement in bed mobility, toileting, and personal hygiene. The information supports a decline in the patient's mobility. Otherwise, there has been no significant decline in the patient's physical functioning. The UAS (Uniform Assessment System) evaluations show some improvement with the ability to perform some ADLs (activities of daily living). Appeal statements note the patient's cognitive and physical functioning have deteriorated and 24 hour assistance is needed for supervision and safety.  Personal care service is not indicated for supervision or when no tasks are being performed. The approved personal care services 56 hours per week are appropriate to meet the patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living). The proposed increase in personal care service to 24 hours per day, live in, is not medically necessary.