Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment, kidney disease, hypertension, arthritis, neuropathy, macular degeneration. 
Treatment: Increase in Personal Care Aide (PCA) Services to 24 Hours Per Day/Live-in, 7 Days Per Week. 

The insurer denied the Increase in Personal Care Aide (PCA) Services to 24 Hours Per Day/Live-in, 7 Days Per Week. 
The denial is overturned. 

The patient is a woman who has conditions including cognitive impairment, kidney disease, hypertension, arthritis, neuropathy, and macular degeneration.  Her son is appealing denial of an increase in personal care aide (PCA) services to live-in 24 hours per day.  Her request was partially approved for an increase in personal care aide (PCA) services to 8.5 hours per day, totaling 59.5 hours per week.  

The patient lives alone.  A Uniform Assessment System (UAS) evaluation performed shows moderately impaired cognition and functional status including total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, phone use, bathing, personal hygiene, dressing, walking, locomotion, and toileting; and extensive assistance with bed mobility and eating.  The patient has declined transferring and ambulating with a walker.  She requires weight bearing assistance from a personal care aide (PCA).  Compared to a Uniform Assessment System (UAS) evaluation performed most recently, the patient's cognitive impairment has progressed from minimally impaired to moderately impaired, and walking and locomotion have progressed from extensive assistance to maximal assistance.  She has a cane, raised toilet seat, shower chair, shower grab bar, walker and incontinence supplies.  Her children are supportive in her care.  

A letter dated from the patient's son notes that his mother has fecal and urinary incontinence overnight and states this cannot be solved with a bedside commode because she is unaware when incontinence occurs.  He states she gets leg cramps at night that need massaging for relief.  She is afraid to be left alone at night.  The letter adds that she needs assistance with activities of daily living (ADLs) as accounted for in the Uniform Assessment System (UAS) evaluation.  

A letter from the patient's provider notes that the patient had notable cognitive decline previously and that has affected her functioning.  The letter notes she is incontinent and needs someone to change her.  It also notes that the patient needs assistance with activities of daily living (ADLs) as already accounted for in the Uniform Assessment System (UAS) evaluation. 

Yes, the proposed increase in Personal Care Aide (PCA) services to 24 hours per day (live-in), 7 days per week is medically necessary. 

Medically necessary services are those which are: 
1) safe; 
2) effective; 
3) a generally accepted national standard of medical practice; 
4) not provided primarily for convenience of the patient or the practitioner; 
5) and the least intensive and/or most appropriate alternative(s) among diagnostic and treatment options. 

The proposed increase in Personal Care Aide (PCA) services to 24 hours per day (live-in), 7 days per week is medically necessary because it is consistent with generally accepted national standards of medical practice. 

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, and/or feeding.  Personal care services are necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  

This patient has multiple chronic conditions including dementia and limited mobility that requires personal care aide (PCA) services for assistance with weight bearing.  Her personal care aide (PCA) hours were recently increased to 59.5 hours per week.  She is requesting services 24 hours per day, on a live-in basis.  Uniform Assessment System (UAS) evaluations performed show the patient requires assistance with all activities of daily living (ADLs) and personal care needs.  The minimal level of assistance is an extensive level.  An assessment performed showed deterioration in functional status compared to an assessment performed most recently which included decline in the patient's cognition, walking and locomotion.  She is incontinent of feces and urine during the night.  Appeal letters note the patient's cognition has declined and she needs nighttime assistance related to incontinence.  She has adaptive equipment for walking and toileting, but requires assistance with transfers.  This patient lives alone and has daytime and nighttime needs that cannot be met with the approved 59.5 personal care aide (PCA) service hours per week.  The proposed increase in personal care aide (PCA) services to 24 hours per day on a live-in basis is medically necessary to meet this patient's need for assistance with activities of daily living (ADLs) and personal care.