Diagnosis: Osteoporosis, Alzheimer's.
Treatment: Personal care aide (PCA) services 5.5 hours per day, 7 days per week, for a total of 38.5 hours per week.

The insurer denied coverage for personal care aide (PCA) services 5.5 hours per day, 7 days per week, for a total of 38.5 hours per week.

The denial is overturned.

The patient is a centenarian with osteoporosis and Alzheimer's disease. The patient lives with spouse and son in a private residence. The insurer approved Personal Care Aide (PCA) services 5.5 hours per day, 4 days per week for a total of 22 hours per week. The request is for 5.5 hours per day, 7 days per week for a total of 38.5 hours per day.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as moderately impaired, decisions consistently poor or unsafe; cues/supervision required at all times. The patient is totally dependent for much of the Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient requires extensive assistance for bathing, personal hygiene, lower body dressing, locomotion, ambulation and toilet transfer/use. The patient is frequently incontinent of bladder and infrequently incontinent of bowel. Limited assistance is needed for upper body dressing and bed mobility. The patient's functional ability has declined when compared to the previous UAS report. The patient's functional needs are daily and not just 4 days per week as approved by the insurer. It has also become more difficult for the patient's elderly spouse to assist. The patient's condition and functional deficits are at a level and unpredictable as to require the requested 5.5 hours/day, 7 days/week for a total of 38.5 hours/day. Based on the enclosed documents reviewed, the patient's health and safety can be more appropriately provided and maintained by the increasing PCA services to 5.5 hours/day, 7 days/week for a total of 38.5 hours/day.

The health care plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

From a physical medicine and rehabilitation perspective, the requested PCA services 5.5 hours per day, 7 days per week, for a total of 38.5 hours per week is medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for personal care aide (PCA) services 5.5 hours per day, 7 days per week, for a total of 38.5 hours per week is substantiated.