Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, status post cerebrovascular accident
(CVA), right-sided hemiplegia
Treatment: Increase in Personal Care Aide (PCA) Services, Level II Basic (per 15 minutes) - 70 Hours Weekly
The insurer denied the Increase in Personal Care Aide (PCA) Services, Level II Basic (per 15 minutes) - 70 Hours Weekly
The denial is upheld.

This male has conditions including vascular dementia, throat cancer in remission, and history of cerebrovascular accident (CVA) with right-sided hemiplegia. The patient is appealing denial of Personal Care Aide (PCA) services 70 hours per week.  He was approved for Personal Care Aide (PCA) services 45 hours per week.  The patient lives alone.  Uniform Assessment System (UAS) evaluation performed shows minimally impaired cognition and functional status as follows: maximal assistance with meal preparation, housework, stairs, and shopping; extensive assistance with managing medications, bathing, dressing, walking, locomotion, and toileting; limited assistance with managing finances, personal hygiene, and eating; and supervision with phone use and bed mobility.  He has urinary incontinence.  Compared to a Uniform Assessment System (UAS) evaluation performed previously, the patient's functional status has not declined.  

An appeal letter from the physician indicates that the patient has deteriorating mental and physical states.  It is noted that the patient is unable to ambulate independently and requires a rollator walker. He is unable to stand for long periods and is at risk for falling.  The physician recommends daily supervision and assistance with activities of daily living (ADLs) as already accounted for in the Uniform Assessment System (UAS) evaluation.  An appeal statement from the agency notes the patient needs assistance with activities of daily living (ADLs) as already accounted for in the Uniform Assessment System (UAS) evaluation, and there is no documentation that the patient's performance of and capacity for participation in activities of daily living (ADLs) has declined.

No, the proposed increase in Personal Care Aide (PCA) services to 70 hours weekly is not medically necessary.
The proposed treatment is not medically necessary because it is not consistent with standard of care.

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 has multiple chronic medical conditions.  He is unable to stand for prolonged periods and has difficulty ambulating without assistance.  He is appealing denial of Personal Care Aide (PCA) services 70 hours per week.  He has been approved for 45 hours per week.  The Uniform Assessment System (UAS) evaluation performed shows that the patient needs assistance with meal preparation, housework, stairs, shopping, managing medications, bathing, dressing, walking, locomotion, toileting, managing finances, personal hygiene, and eating.  Compared to the Uniform Assessment System (UAS) evaluation performed previously, there is no decline in the patient's cognition or functional status.  Appeal statements recommend additional hours based on need for assistance with activities of daily living (ADLs)/instrumental activities of daily living (IADLs), as already accounted for in the Uniform Assessment System (UAS) evaluations.  An appeal letter from the provider also requests additional hours for supervision.  

The approved 45 hours per week is sufficient to meet the patient's needs for assistance with activities of daily living (ADLs) and personal care as noted above.  A Personal Care Aide (PCA) is not indicated for supervision or when no tasks are being performed.  The proposed increase in Personal Care Aide (PCA) services to total 70 per week is not medically necessary.