Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: personal care aide- 7 days per week 8 hours per day- 56 hours per week
The insurer denied personal care aide- 7 days per week 8 hours per day- 56 hours per week.
The determination is upheld.

This is a male patient with a medical history notable for memory issues, diabetes, and chronic pain due to arthritis. The patient is approved for 5 hours per day, 7 days per week (35 hours per week) of personal care services. The patient and his care team requested an increase to 8 hours per day, 7 days per week (56 hours per week) and this request was denied by the health plan.
The patient's nurse practitioner provided a letter of support for the requested increase. The letter details the patient's medical problems and describes his worsening dizziness and memory issues. He has urinary incontinence and requires diapers. The provider feels that it is important that he receive an increase in personal care hours to meet his current level of need. There is no discussion of currently unmet personal care needs.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference. The patient lives alone in a one bedroom apartment. The patient was alert and oriented and able to direct his own care. For his Instrumental activities of daily living (IADLs), he requires maximal assistance for meal preparation, housework, and shopping. He requires extensive assistance for transportation. He requires limited assistance for medications. For his activities of daily living (ADLs), he requires extensive assistance for bathing, toilet use and dressing lower body. He requires limited assistance for hygiene, dressing upper body, walking, locomotion, and toilet transfer. He is independent for bed mobility and eating. He was observed ambulating with a cane and limited assistance; he has an unsteady gait and fair balance. His pain limits his ability to stand and walk for prolonged periods. His skin is intact without pressure ulcers. He is occasionally incontinent of urine (less than daily) and uses pull ups as needed. Compared to a prior assessment, his cognitive and functional status did not show any significant decline. A task tool associated with the most recent assessment recommended 28.71 hours per week to address his personal care needs. At issue is the medical necessity of personal care aide-7 days per week 8 hours per day- 56 hours per week.

The requested health service of personal care aide- 7 days per week 8 hours per day- 56 hours per week has not been demonstrated to be medically necessary for this patient.
The patient has several functional limitations as outlined by the UAS. He primarily requires hands-on assistance for IADLs; he does require some limited assistance with ADLs. He is able to direct his own care and has consumer-directed personal care hours. There is no documentation regarding personal care needs that are not being met by his current allotment of hours that would justify the medical necessity for increased hours. He is receiving 35 hours per week, which is greater than the number of hours recommended by the task tool for his current level of function.