Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 diabetes mellitus with neuropathy, hypertension, coronary artery disease, dizziness and balance impairment.

Treatment:  Personal Care Assistant (PCA) services of 2 aides at 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The insurer denied coverage for PCA services of 2 aides at 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The denial is overturned.

This female has multiple medical conditions and severe functional impairment. The patient lives alone. The patient was receiving Personal Care Services (PCS) 24 hours split shift with her previous insurance plan. When she enrolled in her current plan, services were reduced to PCA 24 hour live-in, plus a 6-hour PCA shift as respite for the live-in aide. According to the patient's daughter, this is not sufficient, as the live-in aide must provide care for 18 hours per day, and she is not able to have adequate rest. The daughter was providing some informal care and she paid for private aides to help for a few additional hours per day to allow the live-in aide to have more rest; but due to the daughter's health problems and diminishing financial resources these additional sources of care are no longer available. Request was made for increase of PCA services to 24 hour split shift, which was denied. 

Functional decline in the elderly is often due to the cumulative effects of various medical conditions causing physical and/or cognitive impairment affecting a person's ability to perform daily activities.  The physician records indicate the patient has dementia. 
The patient has some behavioral problems related to dementia, including screaming (reason was not reported and/or not known), agitation, restlessness. The patient has difficulty sleeping; reported by daughter as no more than two hours of sleep per day.  
The patient has substantial physical impairments that severely limit her mobility; and so when she attempts to sit up in bed, or get out of bed, this needs to be managed the same as for a cognitively intact person with poor mobility; i.e. assistance is needed to help her perform the activity. 

Regarding the patient's physical limitations, it appears that pain is a significant factor contributing to her functional decline. The patient has osteoarthritis, lower back pain due to spondylosis, and thoracic and lumbar back pain following a fall. 

For people with mid to later stages of dementia, pain may not always be expressed with usual verbal communication. Changes in behavior may be signs that the person has pain. Caregivers who are closely involved may be able to interpret various signs of pain in a person with dementia as a result of observing the person on a frequent basis. It appears the patient's need for frequent repositioning in bed is at least partly due to some type of physical discomfort. The daughter reported the patient has history of multiple falls. She indicates that the falls have occurred during rest/sleep periods for the live-in aide before or after the respite PCA was present. The respite PCA shift is 6 hours per night, but the live-in aide cannot be expected to work 18 consecutive hours when the respite PCA is not present. 

The daughter noted the care provided for her mother is very labor intensive. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide assistance for daily activities when necessary throughout the day and night. Based on the information provided for review, the patient's need for assistance with activities of daily living (ADLs) cannot be adequately met within the hours of service provided by a live-in aide. The patient meets criteria for continuous services, split shift.

Personal Care Assistance service, 2 x 12 hours per day, 7 days per week (split shift), total of 168 hours per week are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient

The insurer's denial of coverage for the requested Personal Care Assistance (PCA) Services of 2 aides at 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is reversed. Medical necessity is substantiated.