Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's dementia; osteoarthritis
Treatment: Increase Personal Care Aide (PCA) Lever II Services To 12 Hours per Day, Seven Days per Week, a Total of 84 Hours Per Week, Pre-service
The insurer denied the Increase Personal Care Aide (PCA) Lever II Services To 12 Hours per Day, Seven Days per Week, a Total of 84 Hours Per Week, Pre-service.
The denial is upheld.

The patient is a male. His medical conditions include Alzheimer's dementia, mostly nonverbal, and osteoarthritis. Denial of increase in Personal Care Aide (PCA) Level II Services to 12 hours per day, seven days per week, a total of 84 hours per week, is being appealed. He has been approved for a partial increase from 56 to 66.5 hours per week.

UAS (Uniform Assessment System) evaluation completed shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing medications, shopping, bathing, dressing, and toilet use; maximal assistance with personal hygiene, and toilet transfer; extensive assist with walking, locomotion, bed mobility and eating; and limited assistance with phone use. Has worsening memory and incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functioning with dressing, personal hygiene, toileting, bathing, and bed mobility.

An appeal letter notes recent deterioration in the patient's physical and mental condition. It notes the patient needs constant cuing and supervision. It further notes that the patient has increased frequency of incontinence. A progress report notes the patient is minimally verbal. He ambulates with a walker and has experienced falls when unattended.

No, the requested increase in personal care aide services to 84 hours per week is not 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. Denial of increase is Personal Care Aide (PCA) Level II Services to 12 hours per day, seven days per week, a total of 84 hours per week, is being appealed. He has been approved for a partial increase from 56 to 66.5 hours per week.

This patient has progressive Alzheimer's dementia.  UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). Appeal statements note the patient has progressive deterioration in mental and physical functioning. It is noted that the patient has increased falls and needs constant cuing and supervision. PCA (personal care aide) is not indicated for supervision or when no medical tasks are being performed. This patient's PCA (personal care aide) hours were increased in response to the decline in functioning as noted on the UAS (Uniform Assessment System) evaluations. The approved PCA (personal care aide) 66.5 hours per week is appropriate to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase to PCA (personal care aide) 12 hours per day, seven days per week, a total of 84 hours per week is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.