Diagnosis: Age-related cognitive decline
Treatment: Personal Care Services (PCS) 10 hours/day, 7 days/week, 70 hours/week
The insurer denied PCS 10 hours/day, 7 days/week, 70 hours/week.
The health plan's determination is overturned.

The patient is a female with past medical history of age-related cognitive decline, hyperlipidemia, hypertension, urinary incontinence, osteoporosis, osteoarthritis, vitamin B12 deficiency, and vitamin D deficiency who had been assigned PCA (personal care assistant) services. The patient's husband passed and there was a request to increase PCA services and the patient underwent a telehealth assessment, assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, stairs, and transportation. With tasks of managing finances, managing medication, phone use, bathing, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of personal hygiene, dressing upper body, walking, and locomotion. The patient was assessed at supervision with tasks of bed mobility and eating. Notes from the assessment stated the patient had declined since the death of her spouse and that he helped with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The assessment also stated the patient had no informal help as her daughters did not live nearby.

Personal Care Services (PCS) 10 hours/day, 7 days/week, total of 70 hours/week are medically necessary for this patient.

There is documentation from the patient's primary care physician of increased need of assistance with ADLs and IADLs. There is documentation of medical necessity for this increase and the patient requires more assistance with nutritional support due to weight loss. The patient previously had assistance with ADLs and IADLs from her husband who has since passed, and the patient does not have any informal support. The patient requires assistance with all ADLs and IADLs. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision, but to assist the patient with safe completion of ADLs and IADLs. The plan has suggested physical therapy and occupational therapy to assess for adaptive equipment, but the patient's care needs cannot be met solely with adaptive equipment and medical supplies.

Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCS 10 hours/day, 7 days/week, 70 hours/week are medically necessary for this patient. PCS are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.