Diagnosis: Dementia, Coronary Artery Disease and Depression.
Treatment: Increase of Personal Care Services hours to 8 hours x 7 days (56 hours) per week.
The insurer denied the Increase of Personal Care Services hours to 8 hours x 7 days (56 hours) per week.
The denial is upheld.

The patient is a female with a history of Dementia, Coronary Artery Disease and Depression. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 56 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

No, the 56 hours/week Personal Assistance Services is not deemed medically necessary.

The patient is a female with a history of Dementia, Coronary Artery Disease and Depression. 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 ADLs (activities of daily living) was completed and does not indicated that the currently approved plan of 35 hours/week Personal Assistance Services is insufficient to meet the patient's current needs.

The patient's daughter/POA (power of attorney) provided logbooks of the patient's activities which indicates that she is ambulating with a walker and routinely skips breakfast and dinner due to inability to prepare her meals. However, the UAS (uniform assessment system) documents that the patient ambulates with a cane with no weight bearing support needed. As per the daughter, the patient is able to perform toileting without any support provided. She wears pads for occasional bladder incontinence. There were no falls reported in prior 90 days. The patient was on a soft food diet. Her skin was reported intact. The daughter comes over and prepares breakfast. The PCA (personal care assistant) prepares lunch, and the roommate prepares dinner. Lastly, the patient currently has a Personal Emergency Response System (PERS), which allows her safety monitoring in an effective manner.

There is a final note from the patient's daughter/POA (power of attorney) which states that her mother has been in the ICU (intensive care unit) and as such will require an updated assessment due to worsening functionality. However, until a new assessment can be completed, the proposed treatment 56 hours/week Personal Assistance Services is not deemed medically necessary.