Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal Care Aid Level 2; 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - to total 168 hours per week. 

The health plan denied the Personal Care Aid Level 2; 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - to total 168 hours per week.  The reviewer has overturned in whole the health plan's determination. 

The patient has a past medical history of dementia, hypothyroidism, hyperlipidemia, hypertension, bladder incontinence and bowel incontinence who had Personal Care Assistant (PCA) services 12 hours/day, 7 days/week, to total 84 hours/week. The patient had an office visit with her primary care physician (PCP) noting a recent fall. The patient again saw her PCP following another fall with severe clavicular fracture requiring hospitalization and subsequent rehabilitation stay. The patient saw her PCP with office note stating the patient had fallen multiple times, had a broken wrist, was dependent on others for activities of daily living (ADLs) and transfers and needed an increase in home health hours. The patient had a fall again, was taken to the hospital and diagnosed with Covid and pneumonia and had subsequent hospital stay with discharge to home. Discharge paperwork from the hospital noted the patient should have an evaluation for 24-hour home care and should not be left alone and needed assistance at all times. The patient saw her PCP with subsequent letter noting the patient was post Covid pneumonia with marked deterioration of her baseline and could not perform her ADLs and was a significant fall risk and was episodically confused to her location. The PCP letter also stated the patient was no longer self-correcting and as such recommended 24 hours of assistance and noted patient could not be left alone and required oxygen at 2 Liters. 

The patient underwent a teleconference assessment. 

The requested Personal Care Aide Level 2, 12 hours per day-7 days per week, 12 hours per day-7 days per week (split shift) are medically necessary for this patient.

Prior to the patient's COVID diagnosis with hospitalization her PCP noted she needed increased PCA services. Following the patient's Covid pneumonia and hospitalization there is documentation of worsening of the patient's cognitive and functional status. The patient's PCP documents medical necessity for increased PCA services. The patient is bedbound and requires assistance with bed mobility, transfer toilet, toilet use, walking, and locomotion. The patient has unpredictable and unscheduled care needs that span a continuum of time. The assessment  noted the patient had developed a pressure ulcer. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Considering clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day x 2, split shift 7 days/week, to total 168 hours/week 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.