Diagnosis: history of dementia, hypertension, peripheral vascular disease and coronary artery disease
Treatment: Increase PCA Services For A Total Amount Of 168 Hours Per Week (split shift)
The insurer denied the Increase PCA Services For A Total Amount Of 168 Hours Per Week (split shift)
The denial is overturned.

The patient is a male with a history of dementia, hypertension, peripheral vascular disease and coronary artery disease. 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 168 hours/week Personal Care Aide Services to offer increased ADL (activities of daily living) support.

Yes, the requested Increase PCA (personal care aide) Services For A Total Amount Of 168 Hours Per Week (split shift) is medically necessary.
This is a male with a history of dementia, hypertension, peripheral vascular disease and coronary artery disease. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs).

Although an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and noted that the currently approved plan of 35 hours/week Personal Care Aide Services is sufficient to meet the patient's current needs; the patient's advocate relates this reduced schedule leaves the patient him home alone, completely unassisted for numerous hours/day. This is problematic as he has had numerous recent hospitalizations including a traumatic fall with head injury resulting in bleeding. Furthermore, the patient requires continued support for eating, extensive assistance for dressing upper and lower body, personal hygiene, bed mobility, toilet transfer and toilet use. Furthermore, he continues to require maximum assistance for dressing his lower body, walking locomotion, bathing, meal preparation and medication management. He is totally dependent for housework.

Hence, provision of 168 hours/week Personal Care Aide Services can reasonably be expected to be beneficial for the patient, and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 168 hours/week Personal Care Aide Services is deemed medically necessary.