Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia. 
Treatment: Personal care aide (PCA)/consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week. 
The insurer denied coverage for PCA/CDPAP: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week. 
The denial is upheld. 

This is an elderly patient with chronic medical problems including progressive dementia, hypertension and anxiety. The patient lives with their spouse in a private residence. The patient's daughters are supportive and involved in their care. The insurer approved personal care assistance (PCA) 6 hours/day - 5 days per week; 12 hours/day - 1 day per week and consumer directed personal assistance program (CDPAP) 6 hours per day - 5 days per week; 12 hours/day - 1 day per week - a total of 84 hours per week. The request is for personal care aide (PCA)/consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week, leading to an external review. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as severely impaired. According to the UAS: "Daughter reports cameras are placed in the home due to previous episode of hallucination and falls." The patient is reportedly total dependent for completing Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, personal hygiene, dressing, bed mobility, eating and toilet transfer/use. Extensive assistance is reportedly needed for locomotion and ambulation (however, the patient frequently and independently wanders about the home; particularly at night). The patient is reportedly incontinent of bladder and continent of bowel. There have been 2 or more falls over the prior 30 days. 

Based on the documents submitted for review, the patient's medical condition and functional ability are not at a level or unpredictable as to require the requested PCA/ CDPAP: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week.  The reviewer would agree (which is supported by the submitted Night Time Logs), the patient may benefit from additional monitoring for safety, particularly due to their dementia, wandering and falls risk. The submitted logs document the patient "wandering around the apartment," "hallucinating" and "woke up and took all their clothes off. My dad put pajamas on the patient and put the patient back to bed." Again, based on the documents submitted for review, the requested PCA/CDPAP hours are primarily for safety monitoring as a result of the patient's dementia and wandering. However, PCA/CDPAP hours are approved primarily to provide hands-on assistance for completion of IADL/ADL (activities of daily living) tasks when no one else is available to provide assistance. The patient's health and safety are appropriately provided and maintained at home with the approved PCA/CDPAP 84 hours/week.  The patient also has the option of restructuring and flexibly using the 84 PCA/CDPAP hours weekly to better maintain and meet their functional needs. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care aide (PCA)/consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week is not substantiated.