Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, dementia, bilateral primary osteoarthritis of the knee, hyperlipidemia

Treatment personal care aide (PCA) services level 2 of 8 hours per day, 5 days per week for a total of 40 hours per weeks

The insurer denied coverage for personal care aide (PCA) services level 2 of 8 hours per day, 5 days per week for a total of 40 hours per weeks.	

The denial is overturned. 

This patient has experienced decline in functional status related to her medical conditions. She needs assistance for all Instrumental activities of daily living (IADLs) and most activities of daily living (ADLs). 

The most recent UAS (Uniform Assessment System) provided for review was done. The functional status report indicated the patient was totally dependent or needed maximal assistance for most IADLs, except stairs and transportation (extensive assistance). For ADLs, the patient needed extensive assistance for bathing and lower body dressing, and limited assistance for most other ADLs, except eating (setup help) and bed mobility was noted as independent. The uniform assessment (UAS) reported patient needed limited assistance for bathing and lower body dressing; indicating patient's functional status declined for these ADLs by the time of a later UAS.

Behavioral disturbances often occur with dementia.  The UAS indicates the patient has episodes of hallucinations and delusions; and resists care at times. Treatment of behavioral problems can be challenging. Medications used to manage behavioral symptoms have variable efficacy; their use may be limited by adverse side effects; and are generally reserved for behaviors that can result in harm to the patient and/or caregivers (e.g., patient resists ADL care, medications, food; aggressive action that may cause harm to patient or caregivers; patient distress due to hallucinations or delusions).  Memantine and cholinesterase inhibitors may have some efficacy with behavioral problems. No other medications for dementia related behavioral problems are identified in the available records.

The patient needs assistance with ADLs that typically occur in the morning and evening, and some that occur at various unplanned times throughout the day. Bathing is usually once per day and could be done at any time, though usually in the morning or evening (incontinence may require additional bathing). Personal hygiene and dressing are generally done twice per day, morning and evening. With a PCA schedule covering mid-afternoon to early evening hours, it is not clear who assists the patient with breakfast, lunch, morning ADLs, mobility, and toileting until 2:30pm. If the aide arrives earlier, then the patient would not have assistance later in the day. The daughter's work schedule is not known, but with a request from the daughter (as patient designee) for PCA 8 hours per day, it is reasonable to expect that she is unable to provide care during an 8-hour period of time on weekdays.  

Based on the information provided for review, the patient needs assistance with activities that occur at various routine and unscheduled times during the day, and the care plan needs to accommodate these care needs. It is medically necessary, and in the patient's best interest to have a caregiver present over a longer period of time each day to provide assistance with daily activities in order to ensure proper and safe completion of ADLs; adequate assistance/service with all meals; household tasks as needed; and prevent adverse health and safety events as previously noted.

The UAS identifies the daughter as the only informal helper. Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. With the daughter unavailable during her work hours (which appears to be 8 hours per day, weekdays), then the patient depends on personal care services for assistance with daily activities, including housekeeping tasks, meal preparation and service; routine ADLs (bathing, dressing, personal hygiene), and ADLs that occur at various unscheduled times of the day (toileting/incontinence care, transfers, ambulation).  The patient needs PCA assistance for longer than 5 hours per day to accommodate more of her personal care needs during the time her informal caregiver (daughter) is unavailable.  

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

The insurer's denial of coverage for Personal Care Aide (PCA) Services Level 2 of 8 hours per day, 5 days per week for a total of 40 hours per week is reversed. Medical necessity is substantiated.