Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal care aide 168 hours/week, 12 hours x 2 x 7 days split shift; consumer direct, 1 client. 

The insurer denied Personal care aide 168 hours/week, 12 hours x 2 x 7 days split shift; consumer direct, 1 client. 

The determination is overturned. 

The patient has a past medical history of a cerebrovascular accident (CVA), dementia, urinary incontinence, and bowel incontinence who had been assigned personal care assistant (PCA) services 42 hours a week based on an assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, shopping, and equipment management while maximum assistance with tasks of managing medication, phone use, and transportation. The patient was assessed at extensive assistance with tasks of stairs, bathing, personal hygiene, dressing upper/lower body, and toilet use while supervision with tasks of walking, locomotion, transfer toilet, bed mobility, and eating. 
Notes from the assessment noted the patient had moderate cognitive impairment and due to her wandering the family had installed a camera in her home. The notes also stated the patient had no informal help and a tasking tool estimated 25.28 hours per week. There was a request to increase PCA services and the patient underwent an assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, shopping, and equipment management while maximum assistance with tasks of managing medication, phone use, stairs, transportation, bathing, dressing lower body, and toilet use. With the tasks of personal hygiene and dressing upper body the patient was assessed at extensive assistance while limited assistance with tasks of walking, locomotion, transfer toilet, bed mobility, and eating. 
Notes from assessment stated the patient had severely impaired cognitive skills, was not able to activate the personal emergency response system (PERS), had a decline in activities of daily living (ADL) status over the last 90 days, had a deterioration of overall self-sufficiency in the last 90 days, was waking 5-6 times per night to use the restroom needing human assistance to walk to the bathroom as well as provide toilet hygiene and change pulls ups. Mini-Mental State Examination (MMSE) score was 0/30. The tasking tool estimated 30.81 hours/week. 

The insurer sent a final adverse determination denial notice partially denying the request to increase PCA services with approval of 91 hours/week. The denial stated the patient had enough time to help her with activities of daily living. The denial also stated the patient had equipment in her home to help keep her safe and the patient should use her approved hours flexibly over the course of the week as needed to meet the patient's care needs. The patient's daughter provided a letter to the patient's primary care physician (or provider) (PCP) stating she was starting an external appeal for the patient and they were starting to prepare if the patient needed to be placed in a nursing home. The patient's PCP provided a letter stating the patient had suffered a catastrophic lacunar infarct in the deep left frontal while matter of the brain and the patient had developed worsening dementia as well as an expressive aphasia. The provided also noted the patient was completely nonverbal and no longer interacted with the outside world and had been followed by neurology who felt the patient was suffering from progressive dementia and multi-infarct brain injury. In addition, the provider stated the patient required 24 hour care, needed to be toileted on a regular basis, wore an adult underwear due to urinary and fecal incontinence, and the provider disagreed with denial decision. The patient had a visiting nurse assessment with a patient review instrument (PRI) performed noting the patient would benefit from 24/7 care. At issue is the medical necessity of personal care aide 168 hours/week, 12 hours x 2 x 7 days split shift; consumer direct, 1 client. 

The services are medically necessary. There is documentation from the patient's PCP that the patient requires assistance with all activities of daily living (ADLs)/instrumental activities of daily living (IADLs). The plan's assessment noted the patient was up 5-6 days/night to use the toilet with needed assistance with walking, locomotion, transfer toilet, and toilet use. The patient's care needs in the overnight hours are such that a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. The patient has 24 hour care needs and therefore a task based assessment tool should not have been utilized to calculate PCA hours. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP/PCA services 168 hours/week, 12 x 2 x 7 days split shift are medically necessary for this patient. Personal care services 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.