Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart disease, anemia, hyperlipidemia, dementia, urinary Incontinence, osteoarthritis, stroke. 
Treatment: Increase Personal Care Aide (PCA) Level II: 12 Hours per Day- 7 Days per Week, 12 Hours per Day, 7 Days per Week (Split Shift); a Total of 168 Hours per Week. 

The insurer denied the Increase Personal Care Aide (PCA) Level II: 12 Hours per Day- 7 Days per Week, 12 Hours per Day, 7 Days per Week (Split Shift); a Total of 168 Hours per Week. 
The denial is upheld. 

This is a male patient with medical conditions including heart disease, anemia, hyperlipidemia, dementia, urinary Incontinence, osteoarthritis (OA), and a history of stroke with residual left sided paralysis. He has pain, weakness, fatigue, limited range of motion (ROM), confusion, unsteady gait, and stiffness. The patient lives with his mother in an apartment on the first floor. The patient is appealing the request for Level II personal care aide (PCA) for 12 hours per day, split shift, for a total of 168 hours per week from the current 49 hours per week. 

An assessment performed shows minimally impaired cognition and function status: total dependence with housework, transportation, and locomotion; maximal assistance with meal preparation, shopping, bathing, lower body dressing, walking; extensive assistance with managing finances and medications, personal hygiene, upper body dressing, toileting and eating; and limited assistance with phone use.  This shows decline in bathing and personal hygiene as compared to assessment performed earlier in the year. The patient has the following equipment: bedside commode, cane, scooter, Personal Emergency Response System, raised toilet seat, shower chair, and shower grab bar.  The patient had a fall when trying to stand on his own to use the commode. 

Appeal letter from the patient states the patient is unable to function without aide due to fear of falling.  Appeal letter from medical provider states the patient has a history of cerebral vascular accident (CVA), vascular dementia, cirrhosis, gait abnormality, recurrent falls, hypertension (HTN), neuropathy and chronic back pain.  It states the patient lives alone and requires more assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) as already accounted for in the assessment.  It states the patient is unable to stay home alone safely without supervision. 

No, the proposed treatment, Increase Personal Care Aide (PCA) Level II: 12 Hours per Day- 7 Days per Week, 12 Hours per Day, 7 Days per Week (Split Shift); a 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 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 requires assistance with housework, transportation, locomotion, meal preparation, shopping, bathing, dressing, walking, managing finances and medications, personal hygiene, toileting eating and phone use.  The patient has limited mobility due to residual symptoms of a stroke.  He is noted to be a fall risk.  The patient has: bedside commode, cane, scooter, Personal Emergency Response System, raised toilet seat, shower chair, and shower grab bar.  The patient's doctor is recommending additional hours for nighttime supervision as well as need for assistance with activities of daily living (ADLs).  However, this has already been accounted for in the most recent assessment.  Personal care services (PCS) are not indicated when there are no tasks being performed.  The approved 49 hours per week is sufficient to provide assistance with activities of daily living (ADLs) and personal care as noted above.  The proposed increase in personal care aide (PCA) to a total 168 per week is not medically necessary to meets this patient's need for assistance with activities of daily living (ADLs) and personal care.