Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia
Treatment: Personal Care Aide (PCA) services 24 hours (split-shift) hours per week, 7 days per week.
The insurer denied Personal Care Aide (PCA) services 24 hours (split-shift) hours per week, 7 days per week.
The determination is overturned.

This is a female patient with a history of Alzheimer's dementia, hypertension, congestive heart failure, paroxysmal atrial fibrillation, emphysema, venous insufficiency of the lower extremities, chronic kidney disease stage four (IV), polyosteoarthritis, discogenic spine disease, generalized muscle weakness, hypothyroidism, repeat falls, and urinary incontinence. She lives alone in a private home. The patient was previously approved for Personal Care Aide (PCA) services 8 hours per day, 7 days per week (56 hours per week). The patient and care team requested PCA services 24 hours (split-shift) per week, 7 days per week. The Plan partially denied this request and approved PCA live-in per day, 7 days per week. 
A Uniform Assessment System (UAS) was completed. The patient was assessed at maximal assistance for the tasks of meal preparation and shopping; extensive assistance for tasks of ordinary housework, managing finances, managing medications, stairs, transportation, equipment management, and bathing; and limited assistance for tasks of phone use, personal hygiene, dressing upper body, dressing lower body, walking, locomotion, transfer toilet, and toilet use; and supervision for the tasks of bed mobility and eating.
Another  UAS was completed. The patient was assessed at total dependence for the tasks of meal preparation, ordinary housework, managing finances, and shopping; maximal assistance for tasks of managing medications, phone use, stairs, transportation, equipment management, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use; and extensive assistance for tasks of personal hygiene, dressing upper body, bed mobility, and eating. A tasking tool was used to determine that she requires 50 hours and 34 minutes (min) of aide service per week.
The patient's primary care physician (PCP) provided a letter of support. Her PCP states that she is completely dependent on her home health aide for activities of daily living (ADLs) during the day and night. Due to the patient not understanding her current medical situation, she tries to get up from bed on her own, which leads to falls with injury.  At issue is the medical necessity of Personal Care Aide (PCA) services 24 hours (split-shift) hours per week, 7 days per week.
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, Personal Care Aide services 24 hours (split-shift) per week, 7 days per week is medically necessary.
There is documentation in the UAS of the patient requiring at least extensive assistance with the tasks of walking, locomotion, transfer toilet, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan did not document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies, as the patient's PCP documented that she needs her diaper changed every 2 hours. The insurer should not have utilized a tasking tool to calculate hours given the patient's assistance with unscheduled and unpredictable care needs. The patient lives alone and does not have informal support for the entire time outside of the previously assigned PCA hours. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with ADLs.