Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase in personal care aide (PCA) level 2 services, 14 hours per day 7 days per week for the total amount of 98 hours per week
The insurer denied an increase in personal care aide (PCA) level 2 services, 14 hours per day 7 days per week for the total amount of 98 hours per week.
The determination is overturned.

The patient has a past medical history of dementia, agitation, anxiety, bradycardia, coronary artery disease, carotid stenosis, hypertensive heart disease, aortic valve stenosis, urinary frequency, polyneuropathy with diabetes, gait difficulty and high risk for falls, chronic kidney disease stage III, diabetes mellitus type 2, and osteopenia who had been assigned personal care assistant (PCA) services 7 hours/day, 7 days/week, to total 49 hours/week. There was a request to increase PCA services and the patient underwent an assessment tool. This assessment tool was not available for review but according to the plan's denial the patient was assessed at total assistance for tasks of dressing upper/lower body, personal hygiene, toilet use, eating, meal preparation, medication management, and housework while maximum assistance for task of bathing. The patient was assessed at extensive assistance for bed mobility and toilet transfer while limited assistance with walking and locomotion. The patient's geriatrician saw the patient via telemedicine, noting that the patient's ambulation was compromised by her diabetic neuropathy, dementia, and anxiety as she is unable to utilize a cane or a walker to ambulate safely and requires a wheelchair to help facilitate activities of daily living (ADLs) and to prevent falls. The office note stated the patient was unable to self-propel in a standard wheelchair. The office note also stated the patient had recently been admitted to the hospital with agitation and symptoms were felt to be related to dementia with behavioral disturbance.

The insurer sent a final adverse determination denial notice denying the request to increase PCA hours to 14 hours/day, 7 days/week, to total 98 hours/week. The denial stated the request was not medically necessary and the patient did not meet criteria. The denial also stated the patient's daughter requested an appeal because the daughter said the patient was unable to complete tasks on her own and needed additional assistance and the patient's spouse was unable to fully assist the patient due to his own medical conditions. The denial stated the patient lived with her husband who was supportive and involved in her care, the patient was able to walk with light touch and guidance, the patient had a shower chair, shower grab bar, walker, and incontinence supplies in her home to assist with her personal care needs, and granting additional hours was not provided when tasks were not being performed and for safety monitoring and supervision.

The patient's geriatric provider saw the patient in the office, noting that the patient had bowel and urinary incontinence, was not sleeping at night, was waking up 6-10 times, walking in the room and trying to open the door and closet. The patient was becoming paranoid about her husband trying to abuse her (as her first husband had) and he was her main caregiver. The patient no longer knew how to use a walker or cane and held onto her husband or home health aide when she walked but was unsteady. There was a medical request from the patient's geriatrician for home care specifically asking to reevaluate the patient for 24 x 7 home care. The patient's geriatrician provided a letter requesting external appeal for an expedited determination of 14 hours/day, 7 days/week PCA services. The provider stated the level of care was medically necessary due to her diagnosis of dementia, agitation, anxiety, bradycardia, coronary artery disease, carotid stenosis, stented coronary artery, hypertensive heart disease, nonrheumatic aortic valve stenosis, urinary frequency, polyneuropathy with diabetes and gait difficulty with high risk for falls. The provider noted the patient's Mini-Mental State Examination (MMSE) score was 10 out of 30. The letter stated the patient's current level of care was inadequate due to her cognitive impairment rendering her in need of assistance and surveillance throughout the day, the requirement of meal and medication reminders as she would not eat unless prompted and must be fed at times with a recent weight loss of 9 pounds in 1 month, and required maximum assistance with toileting and has urinary frequency and needs assistance with the commode.

At issue is the medical necessity of an increase in personal care aide (PCA) level 2 services, 14 hours per day 7 days per week, for the total amount of 98 hours per week.

The services are medically necessary.

The patient has documented progressive medical conditions of dementia and neuropathy with an increase in assistance needs that her husband is no longer able to help her with. The insurer did not document a plan to meet the patient's care needs outside of the time she has informal help. The plan assumes the patient has 17 hours of informal help when providing only 7 hours of PCA services. 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 requested increase in PCA hours 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 medical provider documented medical necessity of the need for increased PCA hours. 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, PCA services 14 hours/day, 7 days/week, to total 98 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.