Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Confusion and Dementia
Treatment: Increase Personal Care Aide for 24 Hours Per 
Day, Live-in Per diem, 7 days A Week
The insurer denied: Increase Personal Care Aide for 24 Hours Per Day, Live-in Per diem, 7 days A Week
The denial is partially overturned.

The patient is an elderly male. His conditions include dementia, hypertension, anemia, sciatica, and osteoarthritis. Denial of increase personal care aide for 24 hours per day, live-in per diem, 7 days a week. The health plan approved 5 hours per day, 7 days per week for a total of 35 hours. The patient lives alone. Uniform Assessment System (UAS) evaluation completed recently shows moderately impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing medications, and shopping; extensive assistance with managing finances, bathing, lower body dressing, and toilet transfer; limited assistance with personal hygiene, upper body dressing, walking, and locomotion; supervision with phone use and eating; and independent with toilet use and bed mobility. The patient has infrequent bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed 4 months earlier, there has been a decline with eating to supervision and bed mobility to setup. A letter from the patient's provider notes that the patient's conditions have worsened after a COVID infection. The patient forgets to take his medications and wanders. He had a recent fall. He needs help traveling to the bathroom. The provider recommends HHA (home health aide) increase to 12 hours per day.

The requested Increase Personal Care Aide for 24 Hours Per Day, Live-in Per diem, 7 days A Week is medically necessary, in part.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase personal care aide for 24 hours per day, live-in per diem, 7 days a week is being appealed. The health plan approved 5 hours per day, 7 days per week for a total of 35 hours.
This patient has multiple chronic conditions, including recent COVID-19 infection. Uniform Assessment System (UAS) evaluation completed recently shows the patient does not need assistance with phone use, eating, toilet use and bed mobility. Compared to UAS (Uniform Assessment System) evaluation completed 4 months earlier, there has been a decline with eating to supervision and bed mobility to setup. The appeal statement from his provider notes that he has deteriorated since COVID infection. He forgets to take his medications and wanders. The information provide show that this patient has limitations in physical functioning but is evidenced to have progression of dementia that results in his confusion. Personal care aides (PCA) are not indicated for supervision or when no tasks are being performed. The information provided does not support that he requires live-in support. The approved PCA (personal care aide) 35 hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase PCA to 24 hours per day, live in, is not appropriate. An increase in PCA (personal care aide) to 12 hours per day, 7 days per week for a total of 84 hours is appropriate and medically necessary for this patient.