Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia.
Treatment: Personal care aide (PCA) level 2: 12 hours per day- 7 days per week- for a total of 84 hours per week.
The insurer denied Personal care aide (PCA) level 2: 12 hours per day- 7 days per week- for a total of 84 hours per week.
The determination is overturned.

This is a female patient with a medical history notable for Alzheimer's dementia, congestive heart failure, incontinence, and glaucoma. The patient is approved for 8.5 hours per day, 7 days per week (59.5 hours per week) of personal care aide services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan.

A letter of medical necessity for this appeal was provided by the patient's nurse practitioner. The letter states that the patient requires assistance for all activities of daily living (ADLs) and Instrumental activities of daily living (IADL). She wears diapers 24 hours per day due to incontinence. She is unable to ambulate without assistance.
A letter of support for this appeal was provided by the patient's daughter. The letter states that the patient lives with her but that the daughter is away from the home 12 hours per day for work. The care aide's shift ends at 4:30 currently so the patient is required to go several hours without formal help. She has had numerous personal care needs during that time, such as assistance with toileting and medications for her glaucoma. They have arranged for informal support during that time but need more consistent formal support for the patient during the times that her daughter is working.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was oriented to person only and her cognition was moderately impaired. She is unable to direct her own care. For her IADLs, she requires total dependence for meal preparation, housework, finances, medications, phone use, and shopping. She requires maximal assistance for stairs and transportation. For her ADLs, she requires total dependence for hygiene. She requires maximal assistance for all others, including bathing, dressing, walking, locomotion, toileting, bed mobility, and eating. She is frequently incontinent of urine and stool. A task tool associated with the assessment recommended 63 hours per week to address her personal care needs. At issue is the medical necessity of personal care aide (PCA) level 2: 12 hours per day- 7 days per week- for a total of 84 hours per week.

The requested health service of personal care aide (PCA) level 2: 12 hours per day- 7 days per week- for a total of 84 hours per week is medically necessary for this patient.
The patient requires hands on assistance for all ADLs and IADLs. Her personal care needs can be expected to be continuous throughout the day and night and are both scheduled and unscheduled in nature. Her daughter is able to provide informal support for 12 hours per day, but if she works and is not in the home the remainder of the time, it is medically necessary to provide the patient with personal care assistance the other 12 hours of the day. Without adequate personal care support, she could be left in soiled diapers or miss medication doses, which could adversely affect her health.