Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
 
Treatment: Live in Personal Care Assist Service

The insurer denied the Live in Personal Care Assist Service. The denial was reversed.  

This is an elderly male with a history of dementia, hypertension, hyperlipidemia, cerebral infarction, constipation, limited vision, poor hearing, incontinence of bladder and bowel, gastritis, low back pain. Due to his extensive medical conditions he has severe limitation with his activities of daily living (ADLs). He currently had approval for Personal Care Assist (PCA) service 49 hours per week (7 hours per day x 7 days per week).  A request was made for an increase in services to 24 hours per day x 7 days per week.
Dementia: The patient has diagnosis of Alzheimer's disease.  The description of his cognitive function in the UAS is consistent with middle stages of the disease.  The MMSE score (11/29) is at the lower range of moderate cognitive impairment (borderline moderate/severe). Memory is impaired (short term and procedural); patient is disoriented to time and place; decision making is poor/unsafe and he needs constant supervision.  He is unable to respond appropriately to an emergency (cannot use PERS or call 911; needs extensive assistance to use the phone).  He needs extensive assistance for managing finances and medications.  As dementia progresses, decline of ability to perform ADLs is an expected consequence of the disease; and so it is likely that the patient's functional limitations with ADLs is at least partly due to dementia. 

Urinary incontinence: This problem appears to have developed after a UAS when it was reported that the patient was continent.  The cause is not noted. Some of the patient's other medical conditions may be contributing factors.  Functional incontinence is the inability to reach the toilet in time due to either cognitive or physical limitations. Incontinence usually starts to occur in the middle stages of dementia due to various causes.  As cognition declines, the ability to properly recognize the need to use the bathroom and perform the physical tasks needed for toileting declines.  Any physical problem that restricts the patient's prompt access to a toilet can result in incontinence; and so the patient's physical symptoms (e.g. pain, weakness, fatigue, unsteady gait) may increase frequency of incontinence.

Based on the information available for review, it is apparent that the patient has substantial functional impairment, requiring assistance for all IADLs and ADLs, including ADLs that occur at unscheduled and unpredictable times (i.e. walking, transfers, toileting/incontinence care). The patient's functional status declined for almost all ADLs as described in the UAS within several months.  The patient needs assistance from a caregiver to relieve the stress of performing daily activities (due to pain, weakness, fatigue); help prevent falls and accidents during transfers, walking and toileting; ensure proper hygiene after toileting/incontinence to prevent skin damage; and assist with bed mobility, i.e. turning/repositioning, to prevent pressure injury.  With these considerations, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day and night to provide assistance for these ADLs.  The only informal caregiver identified in the UAS is the patient's daughter who provides limited assistance on the weekend.  Assistance from informal caregivers is voluntary as per NYS regulations for personal care services.  When informal caregivers are not available to provide the necessary care, then PCA services are indicated to provide assistance. 

Live-in personal care assistant services are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.
 
Based on the above, the medical necessity for the live in personal care assist services is unsubstantiated.  The insurer's denial is reversed.