Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: 7 days per week, 7 hours per day; 49 hours per week of personal care worker (PCW) services.
The insurer denied 7 days per week, 7 hours per day; 49 hours per week of personal care worker (PCW) services
The determination is upheld.


The patient has a medical history notable for dementia, history of a transient ischemic attack (TIA), generalized weakness, ataxia, and incontinence. The patient was approved for 4 hours per day, 7 days per week (28 hours per week) of personal care worker services. The patient and his care team requested an increase to 7 hours per day, 7 days per week (49 hours per week), and this request was denied by the health plan.
A letter of medical necessity for this appeal was provided by the patient's physician. The letter states that the patient's physical, cognitive, and functional status have been rapidly deteriorating. He is no longer able to do numerous activities of daily living independently (including cooking, cleaning, bathing, dressing, shopping, and general daily tasks). He wears diapers and requires multiple daily changes which occur at unpredictable times. The letter details the patient's functional deficits in a manner that is congruent with the documentation in the Uniform Assessment System (UAS) (detailed below). There is no discussion of unmet personal care needs.
A letter of support for this appeal was provided by a patient advocate. The letter states that he needs additional help due to his urinary incontinence and inability to do diaper changes by himself.
A Uniform Assessment System (UAS) was completed and was available for review. The patient's cognition was noted to be minimally impaired without further detail provided. From a functional standpoint, the patient requires maximal assistance for meal preparation, housework, managing finances, and shopping. He requires extensive assistance for managing medications and stairs. For his activities of daily living (ADLs), he requires extensive assistance for bathing and dressing lower body. He requires limited assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, toilet use, and eating. He is frequently incontinent of urine and continent of stool. His functional status declined across multiple domains when compared with a prior assessment. A tasking tool associated with the most recent assessment recommended 28 hours per week to address his personal care needs. At issue is the medical necessity of 7 days per week, 7 hours per day; 49 hours per week of personal care worker (PCW) services.

The requested health service/treatment of 7 days per week, 7 hours per day; 49 hours per week of personal care worker (PCW) services have not been demonstrated to be medically necessary for this patient.
The patient has functional limitations which cause him to require assistance for multiple ADLs and Instrumental activities of daily living (IADLs). The documentation in the UAS is congruent with that provided by the treating physician. The number of hours he is currently approved for is what is recommended by his most recent UAS assessment task tool. There have not been any documented issues with unmet personal care needs.