Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease
Treatment: Home Health Care
The health plan denied the requested increase in personal care assistant hours. 
The health plan's determination is overturned.

The patient is a female with a past medical history of Alzheimer's disease, urinary incontinence, diabetes, coronary artery disease, and arthritis.
The patient had been assigned PCA (personal care assistant) services based on assessment tool assessing the patient moderately impaired with memory problems. She has minimal hearing difficult and no vision difficulties. She requires total dependence with the tasks of ordinary housework and meal preparation. The patient was assessed at maximal assistance with the tasks of bathing, limited assistance with personal hygiene and extensive assistance with dressing upper body, dressing lower body, locomotion, transfer toilet, toilet use, and limited assistance with bed mobility and eating. She moves around with a wheelchair. She was noted with a no change in activities of daily living (ADL) status in the last 90 days, with a deterioration in self-sufficiency. It is noted the patient needs one person assistance for transfers and can ambulate with a cane even though she is frequently in a wheelchair. She has frequent bladder incontinent and is occasionally incontinent with bowel. A total of 27.2 hours per week of PCA services is required per the assessment.
The patient's primary care provider wrote a letter of medical necessity. She stated that the patient has multiple medical problems and requires assistance with all activities of daily living and needs medication reminders morning and evening. She noted that the patient cannot ambulate independently and requires extensive assistance for toileting, requiring to urinate 4-8 times a night. She requests 24-hour care.
A letter from the patient's advocate was reviewed which contains additional information that the patient lives alone with some informal assistance from family members, however they cannot provide the amount of informal assistance she needs to meet her needs and 24-hour care was medically necessary.
A letter from the patient's daughter-in-law indicates that the patient is needing overnight care. The daughter-in-law has been providing assistance with getting up to use the bathroom several times a night (sometimes 2-3-hour intervals the per night-sleep logs provided) and the family is now unable to provide overnight care.
This review is regarding the medical necessity of an increase in Consumer Directed Personal Assistance Service (CPCA) services to 24 hours per day, 7 days per week (split shift) Total 168 hours per week. Currently approved hours are 70 hours per week.

The health plan's determination is overturned, in whole.

The requested health service/treatment of Consumer Directed Personal Assistance Services (CDPAS) increase to 24 hours per day, 7 days per week (split shift) for a total 168 hours per week is medically necessary for this patient.
The patient requires assistance with ordinary housework, meal preparation, shopping, bathing dressing, locomotion, and toilet use. She was noted with deterioration in status in her assessment. She is also noted to have unstable gait, dizziness and one person assist for transfers. The patient can use a walker but needs to be helped up and mainly sits in a wheelchair. She is noted to require assistance with toileting during the night, multiple times a night and also suffers incontinence, requiring frequent sheet changes. Thus, she does require overnight hours for assistance with activities of daily living which is medically necessary.