Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive Decline
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 cognitive decline and recent surgery for a malignant bowel mass. The patient is approved for 6 hours per day, 7 days per week (42 hours per week) of level 2 personal care 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 partially denied by the health plan; they did approve an increase to 7.5 hours per day (52.5 hours per week).
The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient has cardiovascular disease, type 2 diabetes, osteoporosis, urinary incontinence, and severe pain due to osteoarthritis. The patient was treated for colon cancer and had multiple surgeries, and now she has a stoma that requires frequent changing of her bag. The letter states that she is no longer able to complete activities of daily living independently and needs assistance throughout the day.
A community advocate provided a letter of support for this appeal. The letter states that the patient has no informal support from her husband, who has advanced dementia. She has been wheelchair bound since her surgery and ostomy placement. She also requires assistance with diaper changes due to urinary incontinence, which she cannot complete independently.
A Uniform Assessment System (UAS) was completed. The review was conducted via teleconference. The patient lives with her husband in an apartment. She was alert and oriented to person and place only. Her recall was 1/3 at five minutes and she was unable to perform procedural tasks. She was noted to become confused and disoriented at times. For her Instrumental activities of daily living (IADLs), she requires total dependence for housework and shopping. She requires maximal assistance for transportation, meals, finances, medications, and stairs. For her activities of daily living (ADLs), she requires total dependence for bathing and dressing lower body. She requires maximal assistance for walking, locomotion, toilet transfer, and bed mobility. She requires extensive assistance for hygiene, dressing upper body, and toilet use. She has frequent urinary incontinence and has a stool ostomy in place. She uses pullups for incontinence care. Since her recent surgery, she has been unable to get out of bed without assistance and requires on her personal care aide (PCA) for most tasks. Compared to a prior UAS, she showed a decline in both cognitive and functional status. 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 is not able to do any transfers without assistance, making her effectively wheelchair bound or bed bound when she does not have an aide available. She is incontinent of urine and requires frequent changes of her ostomy bag. She has had a cognitive decline and, based on the information provided, likely cannot direct all of her care. Her personal care needs are expected to be continuous and unscheduled throughout the daytime, and therefore the full 12 hours per day is medically necessary and reasonable for the patient.