Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal care assistance services, level 2, 24 hours per day, 7 days per week, split -shift. 

The insurer denied personal care assistance services, level 2, 24 hours per day, 7 days per week, split-shift. 
The determination is overturned. 

The patient has a past medical history of osteoarthritis, hyperlipidemia, chronic systolic heart failure, pulmonary hypertension, osteoarthritis, coronary artery disease, osteopenia, hypertension, breast cancer, cyclic neutropenia, and memory difficulties who had undergone a telephonic assessment tool assessing the patient at total assistance with the task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with the tasks of managing finances, managing medication, stairs, equipment management, bathing, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility while limited assistance with tasks of phone use and personal hygiene and supervision only with task of eating. 
The patient's primary care physician (or provider) (PCP) provided a letter requesting an increase in PCA services noting the patient needed assistance to complete activities of daily living (ADLs) both day and night, the patient had an adult daughter who was involved in her care but did not live with the patient, the patient's moderate dementia had progressed over time, the patient's severe osteoarthritis caused progressive difficulty with standing and transferring, the patient had undergone several episodes of physical therapy (PT) and occupational therapy (OT) as well as aggressive management to address her arthritis but these interventions were not successful in restoring function; the patient was now unable to stand secondary to the pain in her knees and was unable to support her weight with her walker due to the pain in her wrists and shoulders. The patient had chronic congestive heart failure and was taking diuretic therapy and when she lay down at night the fluid would be reabsorbed into the circulation and the patient would have increased urination frequency throughout the day and night, the patient had unscheduled needs with toileting both day and night, the patient was able to use a diaper but was unable to change it alone, the patient's soiled diapers must be changed regularly, even overnight, as patient was at high risk for skin breakdown if left in urine or stool for prolonged periods, the patient was now bedbound and too weak to perform bed mobility on her own and was at high risk for the development of decubitus ulcerations, the patient's aides worked hard to provide appropriate nutrition but the patient still needed frequent turning and positioning both day and night to prevent skin breakdown, the patient had increased thirst related to diuretic therapy and required assistance day and night to provide adequate fluids, and lastly given the patient's multiple concrete and unscheduled ADL needs it was the provider's opinion that the patient required personal care assistance throughout the day and night to maintain her health, prevent further loss of function and or hospitalization and Skilled Nursing Facility (SNF) placement was not appropriate for this patient as it was clearly against the patient's expressed wishes. 

The patient had a home visit noting a stage II pressure ulcer on the left buttock that was healing. The home visit note stated the patient was bedbound, and a prescription for a hospital bed, foam mattress, and Hoyer lift were provided. The patient underwent another assessment tool, in person, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, shopping, and locomotion while maximum assistance with tasks of managing finances, managing medication, transportation, bathing, dressing lower body, and toilet use. The patient was assessed at extensive assistance with the tasks of phone use, equipment management, personal hygiene, and bed mobility while limited assistance with task of eating. It was noted the tasks of walking and transfer toilet did not occur. The assessment notes also stated the patient had bedbound status and had no informal help. 
The insurer partially denied a request to increase personal care assistant (PCA) services by approving PCA services 24 hours/day, 7 days/week, live in. The insurer denied the appeal stating the current hours were enough to support the patient's current activities of daily living and additional hours would be for stand-alone safety supervision as there were no additional tasks required based on the patient's functional needs. The denial also stated cognitive prompting was included as part of another task and is not a specific stand-alone task. In addition, the denial encouraged the patient to follow-up with her doctor regarding the symptoms she was reporting and the doctor could help find out what was happening to her health. Lastly, the denial stated the patient did not qualify for split shift PCA services as she had incontinence products that effectively managed the patient's overnight needs and the patient did not have documented medical needs for a task(s) to be performed within a frequency that would not allow a live-in aid to obtain 5 hours of uninterrupted sleep. The patient's medical provider appealed the denial decision and the patient and her family appealed the denial decision.
At issue is the medical necessity of  personal care assistance services, level 2, 24 hours per day, 7 days per week, split -shift. 

Yes, the services are medically necessary. There is documentation of cognitive and functional decline of the patient when comparing the assessments. The patient was granted 24-hour PCA services, live-in,  however, it is documented by her medical provider that the patient requires frequent turning and repositioning and assistance with incontinence cares at such a frequency in the overnight hours that a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. The patient takes diuretic therapy and by the nature of her medical condition of congestive heart failure has increased incontinence care needs in the overnight hours. In addition, the patient has oral hydration needs that require the assistance of a PCA for oral rehydration. Lastly, the patient has a history of a pressure ulcer and requires frequent turning and repositioning at recommended intervals to prevent worsening of decubitus ulcer or new skin breakdown. The patient has unscheduled and unpredictable care needs that span a continuum of time and as above, the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. 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). 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 24 hours/day, 7 days/week, split-shift, 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.