Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Lewy Body Dementia
 
Treatment:  Personal Care Aide (PCA) services 12 hours per day, 7 days per week (total of 84 hours per week)

The insurer denied Personal Care Aide (PCA) services 12 hours per day, 7 days per week (total of 84 hours per week).  The denial was reversed.   

This is an elderly patient with a history of Lewy body dementia with behavioral disturbances and Parkinson's disease.  Due to her declining physical and cognitive conditions and his inability to follow directions, a request was made for an increase in personal care aide (PCA) from 9.5 hours per day, 7 days per week to PCA services 12 hours per day, 7 days per week.  It was reported that the patient is totally incontinent of her bladder and bowel.  She requires maximal assistance for walking, transfers, and bed mobility. 

The patient's functional disability can result in serious complications if his ADLs are not managed properly throughout the day and night.  The patient is totally incontinent (bladder and bowel). It is likely that the patient has episodes of incontinence during the 14.5 hours per day/night that the PCA is not present.  The patient requires assistance from a caregiver for all aspects of toileting and incontinence care, including weight-bearing assistance if the patient uses the toilet, and weight bearing assistance to manage all the aspects of incontinence care (turning the patient in bed or helping him stand up for cleaning and hygiene, changing pads/briefs/clothes).  Without proper and prompt hygiene/cleaning after toileting and incontinence, the patient is at risk for incontinence associated skin damage (e.g. dermatitis, fungal infection, increased risk of pressure ulcers). 

The patient needs maximal (weight-bearing) assistance for bed mobility.  The physician was concerned that the patient stays in bed in one position for up to 15 hours per day (when PCA is not present).  It is not clearly noted in the UAS whether the wife is able to provide repositioning and incontinence care through the night.  The development of pressure ulcers is a serious complication of immobility, with additional risk when associated with incontinence.  The patient needs extensive (weight-bearing) assistance for walking and transfers.  The patient is at high risk for falls due to balance and gait problems (associated with motor dysfunction from Parkinsonism and LBD), and poor judgment/safety awareness due to dementia.  It is not clear whether the patient attempts to get out of bed at night; but if he does, it is necessary to have a caregiver present to assist with transfer in and out of bed and with ambulation.  Falls in the elderly are associated with serious injuries (fractures, head trauma), substantial morbidity and increased risk of death.

The patient's family member has been providing some assistance with ADLs and IADLs; however, the physician noted that this is becoming more difficult for her to manage.  Providing such a high level of weight-bearing assistance during extended periods of the day and night can cause considerable stress for informal caregivers.  Considering additional PCA hours are requested (total of 12 per day), it is reasonable to conclude that the wife is having difficulty providing care for her husband when the PCA is not present.  Assistance from informal caregivers is voluntary, as per NYS regulations for personal care services.  When informal caregivers cannot consistently provide assistance with ADLs for the time period needed, then PCA services are medically necessary to provide assistance with ADLs when needed throughout the day and night. 

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

Based on the above, the medical necessity for Personal Care Aide (PCA) services 12 hours per day, 7 days per week (total of 84 hours per week) is substantiated.  The insurer's denial is reversed.