Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, diabetes, coronary artery disease
Treatment: Home Care/Personal Care HHC - Level II - per 15 Minutes - Increase To 84 Hour(s) per Week, Pre-service
The insurer denied the Home Care/Personal Care HHC - Level II - per 15 Minutes - Increase To 84 Hour(s) per Week, Pre-service
The denial is overturned.

This male patient has medical conditions including dementia, status post cerebral vascular accident with residual left-sided hemiplegia, dysphagia, diabetes, hypertension, and coronary artery disease (CAD).  He is appealing denial of personal care services (PCS) 84 hours per week.  He was partially approved for increase in personal care services from 28 to 49 hours per week.  

The patient lives with his spouse in an apartment.  Appeal application notes that the patient is wheelchair/bedridden due to cerebral vascular accident (CVA).  Physical conditions has been worsening.  He was admitted to rehab for a period of time.  At the time of discharge, he required moderate assistance with lower body dressing; supervision with rolling left to right and sit to lying, and moderate assistance with sit to stand.  He is non-ambulatory.  He is wheelchair bound.  He needs position change every two hours.  He is incontinent of bowel and bladder.

Uniform Assessment System (UAS) evaluation completed shows cognition minimally impaired and functional status: total dependence with meal preparation, housework, managing finances, shopping, bathing, dressing, locomotion, and toilet use; maximal assistance with managing medications, phone use, personal hygiene and toilet transfer; and extensive assistance with bed mobility and eating.  A prior Uniform Assessment System evaluation was completed previously.

Yes, the proposed treatment is medically necessary.
The proposed treatment is consistent with generally accepted standards of medical practice.

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.  

This patient has multiple chronic conditions.  He is status post cerebral vascular accident and wheelchair/bedbound due to residual left-sided hemiplegia.  He is appealing denial of personal care services 84 hours per week.  He was partially approved for increase personal care services from 28 to 49 hours per week.  Uniform Assessment System evaluation completed shows the patient needs assistance with all activities of daily living (ADLs) and personal care needs.  His physical condition has worsened since the Uniform Assessment System evaluation completed previously.  He is totally dependent with activities of daily living (ADLs)/instrumental activities of daily living (IADLs), with the exception of extensive assistance needed for bed mobility and eating.  He is incontinent of bowel and bladder.  He requires turning/repositioning every two hours.  This patient has significant limitations that require more than the approved personal care services 49 hours per week.  The proposed personal care services 84 hours per week is medically necessary to meet this patient's needs for assistance with activities of daily living and personal hygiene, as noted above.