Diagnosis: Alzheimer's disease, Coronary Artery Disease, Urinary incontinence and CVA with residual hemiplegia
Treatment: Personal Care Aide (PCA) 12 Hours per Day - 7 Day(s) per Week- a Total of 84 Hours per Week
The insurer denied the Personal Care Aide (PCA) 12 Hours per Day - 7 Day(s) per Week- a Total of 84 Hours per Week.
The denial is overturned.

The patient is a male with a history of Alzheimer's disease, Coronary Artery Disease, Urinary incontinence and CVA (cerebrovascular accident) with residual hemiplegia. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the Personal Care Aide (PCA) 12 Hours Per Day - 7 Day(s) Per Week- A Total of 84 Hours Per Week is medically necessary.

This is a male with a history of Coronary Artery Disease, Chronic Kidney Disease, Dementia and Stroke. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent correspondence from the patient's medical provider indicates that due to worsening functionality, generalized weakness and gait ataxia, the patient requires more assistance for completion of all of his ADLs (activities of daily living). For these reasons, the health plan's currently approved regimen of 56 hours per week is not sufficient to meet the patient's needs. Therefore, the proposed treatment 84 hours/week Personal Assistance Services is deemed medically necessary.