Diagnosis: History of glaucoma, coronary artery disease,
anxiety disorder, dementia, depression and stroke
Treatment: Increase Personal Care Services, 24 hours, seven days a week (split-shift)
The insurer denied the Increase Personal Care Services, 24 hours, seven days a week (split-shift).
The denial is upheld.

The patient is a female with a history of glaucoma, coronary artery disease, anxiety disorder, dementia, depression and stroke. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).

Appeal review requested for potential approval of 24 hours, seven days a week (split-shift), Personal Assistance Services to offer increased activities of daily living (ADL) support.

No, proposed treatment of 24 hours, seven days a week (split-shift), Personal Assistance Services is not deemed medically necessary.

This patient is a female with a history of glaucoma, coronary artery disease, anxiety disorder, dementia, depression and stroke. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).

However, an in-home assessment of the patient's functionality and ability to perform activities of daily living (ADLs) was completed and revealed that the currently approved plan of 84 hours per 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 24 hours, seven days a week (split-shift), Personal Assistance Services is not deemed medically necessary.