Diagnosis: Cognitive decline
Treatment: Increase Personal Care Services, Level 2 to 9 Hours Per Day 7 Days Per Week, total of 63 Hours Per Week
The insurer denied the Increase Personal Care Services, Level 2 to 9 Hours Per Day 7 Days Per Week, total of 63 Hours Per Week
The denial is overturned

The patient is a female. The request is for increase in personal care service hours.

The requested increase is to 9 Hours Per Day 7 Days Per Week, total of 63 Hours Per Week from 42 hours per week.

Yes, the requested increase in personal care service to 63 hours/week is medically necessary.
The patient resides alone in a one-bedroom apartment with elevators. She needs extensive assistance with bathing and dressing. She also needs assistance with walking, transfers and toileting. She can walk with a cane. She needs assistance with meal preparations, housework and shopping. She also has reported a fall at home.

The patient is experiencing rapid cognitive and functional decline. The requested increase in personal care services are medically necessary for patient safety.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient is experiencing rapid cognitive and functional decline. The requested increase in personal care services are medically necessary for patient safety.