Diagnosis: Alzheimer's dementia.
Treatment: Personal Care Services for Eight Hours a Day, Seven Days a Week for a Total of 56 Hours per Week.
The insurer denied the Personal Care Services for Eight Hours a Day, Seven Days a Week for a Total of 56 Hours per Week.
The denial is upheld.

This patient is a female with conditions including Alzheimer's dementia. She is appealing denial of Personal Care Services for eight hours a day, seven days a week, for a total of 56 hours per week. The Plan has approved personal care services (PCS) five hours a day, seven days a week, for 35 hours per week.

Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, phone use, bathing, and lower body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toileting; and supervision with bed mobility and eating.

An appeal letter from the provider notes the patient needs eight hours a day of supervision to keep her safe. An appeal letter from another provider notes the patient has progressive declining dementia and has been exhibiting behaviors concerning for safety and eight hours home health aide (HHA) is needed for the patient's safety and well being. It states the patient retains some functional independence.

No, the proposed treatment is not medically necessary.
Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.

This patient has progressive Alzheimer's dementia. She is appealing denial of Personal Care Services for eight hours a day, seven days a week, for a total of 56 hours per week. The Plan has approved personal care services (PCS) five hours a day, seven days a week, for 35 hours per week. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with meal preparation, housework, shopping, managing finances and medications, phone use, bathing, lower body dressing, personal hygiene, upper body dressing, walking, locomotion, and toileting. Appeal statements note the patient has progressive decline in dementia and needs increased personal care services (PCS) for safety and supervision. Personal Care Services (PCS) are not indicated for supervision. The approved personal care services (PCS) 35 hours per week is appropriate and medically indicated to meets the patient's needs for assistance with activities of daily living (ADLs) and personal care. The proposed increase in personal care services (PCS) to total 56 per week is not medically necessary.