Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease
Treatment: Personal Care Assistant (PCA) Services: 7 Days x (by) 24 Hours (Split Shift)
The health plan denied the Personal Care Assistant (PCA) Services: 7 Days x (by) 24 Hours (Split Shift) as not medically necessary.
The health plan's determination is overturned.

The patient is a female with a past medical history of Alzheimer's dementia, urinary incontinence, anxiety, depression, atrial fibrillation, chronic obstructive pulmonary disease (COPD), coronary artery disease, congestive heart failure, glaucoma, hypertension, and gastroesophageal reflux disease who had been assigned personal care assistant (PCA) services 12 hours/day, 6 days/week and 7 hours/day 1 day/week to total 79 hours/week. There was a request to increase PCA services. The patient's assessment found her to need total assistance with tasks of ordinary housework and shopping while maximum assistance with tasks of meal preparation and dressing lower body. With tasks of managing finances, managing medication, phone use, stairs, transportation, equipment management, bathing, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use the patient requires extensive assistance while limited assistance with task of eating. The patient was assessed at supervision with task of bed mobility. The patient underwent another assessment via video. The patient required total assistance with task of shopping while maximum assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, transportation, bathing, dressing lower body, and toilet use. With tasks of managing medication, dressing upper body, walking, locomotion, and transfer toilet the patient was assessed and extensive assistance while limited assistance with task of personal hygiene. The patient was assessed at set up only with task of phone use while supervision with task of eating and independent with task of bed mobility. The insurer sent final adverse determination denial notice changing PCA services to 24 hours/day, live-in, 7 days/week. The patient's medical provider stated the patient had history of Alzheimer's dementia with severe depression and psychosis as well as worsening memory, confusion, paranoid delusions, depression, and anxious mood. The patient had unstable gait and difficulty walking, was unable to comprehend to keep the information, had developed agitation at night due to paranoid delusions that people were against her, had attempted to leave her house multiple times at night due to paranoia, had poor activities of daily living (ADLs), was unable to take care of herself, forgets to eat, and had poor social support. The provider noted the patient had started antipsychotic medications but had not improved and needed an increase in home health aide hours.

At issue is the medical necessity of the requested health service/treatment of PCA services: 7 days x (by) 24 hours (split shift) continuous care.

The health plan's determination of medical necessity is overturned in whole.

There is documentation of medical necessity of split shift services by her medical provider who documented the patient's medical condition of Alzheimer's disease with sundowning/psychosis which had not been responsive to medication changes. The patient requires extensive assistance with walking and locomotion. Given her unpredictable episodes of ambulation due to her medical condition of Alzheimer's disease, she has care needs that span a continuum of time. 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 in the overnight hours would not allow a PCA 5 hours of uninterrupted sleep. The patient's care needs cannot be met solely with adaptive equipment and medical supplies.