Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia.
Treatment: Personal Care Services, 2-12 hour split shifts per day 7 days per week(Monday through Sunday).
The insurer denied Personal Care Services, 2-12 hour split shifts per day 7 days per week(Monday through Sunday).
The determination is upheld.

The patient has a past medical history of Alzheimer's dementia, major depressive disorder, atrial fibrillation, osteoarthritis, diabetes mellitus type 2, hypertension, hyperlipidemia, asthma, benign prostatic hyperplasia (BPH), coronary artery disease, and urinary incontinence who had been assigned personal care assistant (PCA) services 6 hours/day times (x) 7 days/week to total 42 hours/week but shared the same amount of services with his wife to total 84 hours/week of PCA services.
On the assessment tool, the patient was assessed at total assistance with the task of ordinary housework while maximum assistant with tasks of meal preparation, managing finances, managing medication, phone use, and shopping. The patient was assessed at extensive assistance with the tasks of stairs, transportation, equipment management, bathing, personal hygiene, dressing upper/lower body, and toilet use while limited assistance with tasks of walking, locomotion, and transfer toilet. With the tasks of bed mobility and eating, the patient was assessed at supervision.
The patient's psychiatrist provided a letter stating the patient was losing his level of functioning due to dementia and multiple medical problems. The letter further stated the patient was unable to organize his daily activities and was unable to take care of his daily routines. In addition, the letter stated the patient's daughter noted that the patient had episodes of forgetfulness where he would leave the stove on overnight. Lastly, the psychiatrist stated as a result of the patient's cognitive and physical limitations, he was in need of constant supervision and assistance during the day and night and was in need of 12 x 12 hours of home health assistance.
The insurer provided a final adverse determination denial notice denying the request to increase PCA services stating it was not medically necessary. The denial stated additional hours would be for stand-alone safety supervision as the are no additional tasks required based on the patient's functional needs. The denial also stated a new assessment was needed in order to determine if the request was medically necessary and the insurer had made 3 attempts to contact the patient and there was no return call. The denial further stated an assessment was required to receive services and the patient may be in jeopardy of losing services if they were not able to contact and assess the patient. The patient had an office visit with the primary care physician (PCP) as a new patient noting that he ambulated with a cane, was alert and oriented times (x) 2-3, had periods of wandering around the house and in the dark in the night and had left to the street. The office note also stated the patient required constant supervision and was started on Risperdal. Lastly, the office notes stated the patient would strongly benefit from a 24-hour home health aide since his children do not live next to patient.
At issue is the medical necessity of Personal Care Services, 2-12 hour split shifts per day 7 days per week(Monday through Sunday).
The services were not medically necessary. The patient had the last assessment with reported worsening physical and mental functioning. The patient needs to complete a current assessment to determine further medical necessity and based on the assessment provided increased PCA services are not medically necessary. The requested increase in PCA services would be for safety and supervision. 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 (split-shift), 7 days/week, are not medically necessary for this patient.