Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoporosis, Alzheimer's disease.
Treatment:  Increase Personal Care Aide (PCA) Services for a Live-in Per Diem; 24 Hours per Day, 7 Days per Week.

The insurer denied: Increase Personal Care Aide (PCA) Services for a Live-in Per Diem; 24 Hours per Day, 7 Days per Week.  The denial is overturned.

This elderly female patient is appealing denial of increase personal care aide (PCA) services for a live-in per diem; 24 hours per day, seven days per week.  The health plan approved 59.5 hours per week. Uniform Assessment System (UAS) evaluation show the patient needs assistance with dressing, hygiene, bed mobility, walking, locomotion, bathing, toileting, meal preparation and housework.  The plan denied increase in hours because there is no change between Uniform Assessment Systems evaluations.  
The patient no longer has informal support. Statements from the patient's daughter note that the patient has declined in mental capabilities and ability to ambulate to care for herself or be left alone.  She constantly falls asleep.  She has fallen out of bed and off the toilet.  She has incontinence and uses the bathroom four to five times overnight.  The patient's daughter also notes the patient needs regular turning/repositioning due to sacral tissue injury. A statement from the doctor notes the patient has conditions including osteoporosis with a pathological fracture, diabetes, gait instability, lumbar stenosis and Alzheimer's disease.  She has a decline in mental capacity and physical mobility. She's had three falls in two months.  Her ambulation is deteriorating.  She requires constant supervision due to cognition and is dependent with activities of daily living (ADLs). A statement from the doctor notes the patient is not able to care for herself and requires full assistance with activities of daily living.

The proposed treatment is medically necessary.

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 including Alzheimer's disease.  She is appealing denial of increase personal care aide (PCA) services for a live-in per diem; 24 hours per day, seven days per week.  The health plan approved 59.5 hours per week.  The plan denied increase in hours because there is no change between Uniform Assessment System evaluations.  However, several appeal statements have been provided for review that indicate that there has been both a mental and physical decline.  The patient is a fall risk due to gait instability and has had three recent falls.  She needs assistance with activities of daily living to include assistance with overnight toileting up to five times per night.  She no longer has informal support.  The appeal statements support the patient's need for assistance with activities of daily living that include overnight assistance with frequent toileting.  These needs cannot be met with the approved personal care aide (PCA) 59.5 hours per week.  The proposed increase personal care aide services for a live-in per diem; 24 hours per day, seven days per week is medically necessary.