Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Personal care aide (PCA) level 2: 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The insurer denied the Personal care aide (PCA) level 2: 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.  The determination is overturned.

The patient has a past medical history of Alzheimer's dementia, heart failure, atrial fibrillation with chronic anticoagulation, pleural effusion, chronic pain, and a heel ulcer who had been assigned personal care assistant (PCA) services 8 hours/day, 7 days/week, to total 56 hours/week based on assessment tool performed telephonically. The patient was hospitalized for three days with sepsis. There was a request to increase PCA services to 12 x 12 hours/day, split-shift, 24 hours/day, to total 168 hours/week.
The insurer sent an initial adverse determination denial notice stating that the patient's last assessment was completed by telephone and based on this assessment the patient's daughter directs the patient's care, the patient has a raised toilet seat, shower chair, shower grab bar and walker in her home to assist with her needs, had time allotted for meal preparation, was able to transfer on an off the toilet with guidance, was able to take care of her toileting needs with some assistance, was able to transfer to and from a bed to chair with guidance, and was receiving physical therapy (PT). Lastly, this denial stated the patient's current PCA hours were appropriately and safely meeting her assistance needs. The patient was hospitalized for three days with altered mental status and anemia. The PT note stated the patient had normal range of motion, had 3/5 weakness in all extremities, was moderate assistance with rolling, was moderate assistance with semi-Fowlers to sitting at the edge of the bed, was moderate assistance with sit to/from standing, was moderate assistance with lifting/lowering trunk with rolling walker, and was unable to maintain standing for more than one second.
The patient's cardiologist provided a letter stating the patient's medical conditions; the patient had been falling at night when alone, the patient has had injuries to the shoulder, ankle, ribs, lower back, and hip, the patient needed increase in PCA hours to 12 x 12, and the patient has confusion with increased wandering. The insurer sent a final adverse determination denial notice denying request to increase PCA services stating it was not medically necessary and the patient did not meet criteria. The denial stated the patient's abilities to perform physical functioning stayed the same since her prior assessment. The denial further stated additional hours were not provided for supervision, companionship, or when the aide is not performing tasks.

The patient's neurologist requested an expedited appeal of the denial decision and provided a letter stating the patient was under his care for severe Alzheimer's disease. The letter stated the patient had severely impaired cognitive functioning, was not able to follow directions, had difficulty communicating, and had impaired concentration. The patient had hallucinations, delusions, and paranoia and she became frightened and agitated, more so at night. The letter stated the patient needed supervision and assistance 24 hours/day. In addition, the letter from neurologist stated the patient had swallowing disorder and was at risk for aspiration, was debilitated from her recent hospitalizations, was incontinent of bowel and bladder, needed to be changed, bathed, and cleaned after incontinence episodes which was an unscheduled need, was not aware of the time of day and needed assistance at night specifically waking 3-5 times at night demanding help with various concerns, the provider had asked for 12 x 12 hour care over a year ago and patient had declined further. The provider also stated the patient was too weak to turn in bed without assistance, was unable to get out of bed without full support, was unable to walk with her walker, and there had been no substantive improvement in physical functioning since her physical therapy (PT) evaluation when in the hospital. The neurologist stated the patient was unable to attend to any of her activities of daily living (ADLs) independently and needed supervision, hands-on assistance, instructions, prompting, and reminders for, but not limited to, meal preparation, laundry, shopping, exercise, bathing, grooming, toileting, dressing, medications, eating, and escort to appointments. Lastly, the patient's neurologist stated full time 2 x 12 x 7 PCA care is medically necessary for the patient.

At issue is the medical necessity of  personal care aide (PCA) level 2: 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

Yes, the requested services are medically necessary.

The patient has a documented chronic progressive medical condition of severe Alzheimer's disease with worsening mental and physical function. The plan made the denial decision based on an assessment completed months prior. The patient had a change in mental and physical functioning compared to the last telephonic assessment. The patient has the diagnosis of Alzheimer's dementia with an increase in hallucinations and paranoia causing her to be up at night 3-5 times with the need for assistance with ADLs of locomotion, walking, personal hygiene, transfer toilet, and toilet use. The patient's attending physician noted due to the patient's care needs in the overnight hours a PCA would not be able to obtain 5 hours of uninterrupted sleep. The patient has unscheduled and unpredictable care needs over a continuum of time and the insurer failed to 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). 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 12 x 12 hours/day, 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.