Diagnosis: Alzheimer's Disease, Meniere's Disease.
Treatment: Personal care services, level II, seven hours/day, seven days/week, total 49 hours/week.

The insurer denied the Personal care services, level II, seven hours/day, seven days/week, total 49 hours/week. The denial is upheld.

The patient is a male with a history of Alzheimer's dementia, Meniere's disease and low back pain. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs).

Appeal review requested for potential approval of an increase in personal assistance services to seven hours/day, seven days/week, total 49 hours/week to offer increased ADL support.

No, the proposed treatment of an increase in personal assistance services to seven hours/day, seven days/week, total 49 hours/week is not deemed medically necessary.

An in-home assessment of the patient's functionality and ability to perform ADLs was completed and revealed that the currently approved plan of 37 hours/week personal assistance services is sufficient to meet the patient's current needs. There is no additional documentation, which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment of an increase in personal assistance services to seven hours/day, seven days/week, total 49 hours/week is not deemed medically necessary.