Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post falls at home, compression fractures, Alzheimer's dementia, glaucoma, arrhythmia, and anxiety. 
Treatment: Increase Personal Care Services, Level 2 to 24 Hours Per Day, 7 Days Per Week (split shift), Total of 168 Hours Per Week. 

The insurer denied the Increase Personal Care Services, Level 2 to 24 Hours Per Day, 7 Days Per Week (split shift), Total of 168 Hours Per Week. 

The denial is upheld. 

The patient is a female with conditions including status post falls at home, compression fractures, Alzheimer's dementia, glaucoma, arrhythmia, and anxiety.  She is appealing denial of increase to 24 hours, split shift PCS (personal care service) hours per day.  She has been approved for 70 hours per week. 

The patient lives alone in an apartment.  Assessment performed shows minimally impaired cognition and functional status; total dependence with meal preparation, housework, and shopping; maximal assistance with managing medications, transportation; extensive assistance with managing finances, phone use, bathing, personal hygiene, dressing, locomotion, and toileting; and limited assistance with bed mobility.  She uses wheelchair for locomotion.  She is able to ambulate short distances with walker with assistance. 

Statement from the health plan notes that the patient was hospitalized after falls in the bathroom.  She was hospitalized for vertebral fractures.  

The patient has short-term memory loss.  She is able to make decisions.  She is frequently incontinent. She is able to reposition herself in the bed.  Daughter states there patient has increased weakness, low endurance and decline in functional status.  Appeal letter from the provider states the patient was admitted for short term rehabilitation.  States since admission, the patient has significant decline in cognitive, functional and medical status and now requires extensive assistance for all ADLs (activities of daily living).  States the patient requires around-the-clock supervision.  States she is at high risk for falls.  

No, the Increase Personal Care Services, Level 2 to 24 Hours Per Day, 7 Days Per Week (split shift), Total of 168 Hours Per Week, is not medically necessary.  

Medically necessary services are those which are safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner,  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 was approved for 70 PCS (personal care service) hours per week based on assessment.  She is appealing denial of 24 hours, split shift care.  The assessment shows the patient needs assistance with meal preparation, housework, shopping, managing medications, transportation, managing finances, phone use, bathing, personal hygiene, dressing, locomotion, toileting and bed mobility.  She has dementia with minimally impaired cognition.  She uses a walker and wheelchair for locomotion.  She has a history of falls resulting in hospitalization.  Appeal letter from her doctor notes there is decline in the patient status and around the clock supervision is needed as well as need for assistance with ADLs (activities of daily living) that are already accounted for in the assessment.  The approved 70 hours per week are sufficient to provide assistance with ADLs (activities of daily living) and personal care as noted above.  PCS (personal care service) is not indicated for supervision or when there are no tasks being performed.  The proposed increase in PCS (personal care service) to 24 hours, split shift care is not medically necessary to meet this patient's need for assistance with ADLs (activities of daily living) and personal care.