Diagnosis: Impaired memory, arthritis, headaches and dizziness
Treatment: Personal Care Aide 7 Days for 12 Hours for a Total of 84 Hours Per Week
The insurer denied: Personal Care Aide 7 Days for 12 Hours for a Total of 84 Hours Per Week
The denial is upheld.

This elderly female is appealing denial of personal care aide seven days, 12 hours, for a total of 84 hours per week. The plan approved 49 hours per week. The request for increase was denied because the most recent documentation does not show changes that affect functional or medical needs.
A letter from her provider notes that the patient has multiple chronic medical conditions. She is dependent on family and home care workers for her activities. Pain due to arthritis, headaches and dizziness impair her ability to ambulate and complete activities of daily living (ADLs). She has a history of multiple falls. She has impaired memory. An increase in home care hours is recommended. A progress note has also been provided for review.

The proposed treatment is not medically necessary.
Personal care 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 multiple chronic medical conditions. She is appealing denial of personal care aide (PCA) seven days for 12 hours for a total of 84 hours per week. The plan approved 49 hours per week. The request for increase was denied because the most recent documentation does not show changes that affect functional or medical needs. A letter provided by her provider notes that the patient has impaired mobility due to arthritis, headaches and dizziness and recommend an increase in home care hours. The information provided does to support tasks that require a personal care aide (PCA) 84 hours per week. Personal care aide is not indicated for management of chronic medical conditions or for supervision. The proposed increase in personal care worker to 84 hours per week is not medically necessary.