Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease
Increase Personal Care Aide (PCA) Level II: 24 Hour Continuous Care, 7 Days Per Week
The insurer denied the Increase Personal Care Aide (PCA) Level II: 24 Hour Continuous Care, 7 Days Per Week.
The denial is upheld. 

The patient is a female. She has a diagnosis of Alzheimer's disease.  An increase in PCA (personal care assistant) services from level II, 24 hour live-in to continuous is being requested on the patient's behalf.

The patient was hospitalized with ARDS (acute respiratory distress syndrome). She went to went rehab for a little over a week.  Prior to hospitalization, the patient was receiving 30 hours PCA (personal care assistant) service.  The patient lives with her spouse and son.  The spouse reports that the patient has declined in cognition and physical status.

Assessment performed showed that the patient has severely impaired cognition.  The patient's functional status was as follows:  total dependence with meal prep, housework, managing finances, managing medications, phone use, shopping, bating, personal hygiene, dressing, locomotion, bed mobility, eating, and toileting.  The patient is non ambulatory.  Hoyer life is used for transfers.  Three-night sleep observation study performed showed the patient sleeps 10 PM - 7 AM.  Two nights at 2 AM and 4 AM she needed to be changed after a bowel movement.  Otherwise, no hands-on care was needed.  The patient's doctor attested to the need for 24 hour, live-in PCA (personal care assistant) services.

No, the Increase Personal Care Aide (PCA) Level II: 24 Hour Continuous Care, 7 Days Per Week is not medically necessary.

Level II personal care service is indicated for individuals that need assistance with housekeeping, cleaning, meal preparation, grocery shopping, and laundry as well as assistance with personal needs, including bathing, dressing, grooming, toileting, walking, feeding, assisting with administering medications, preparing meals with special diets, and routine skin care. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the provide obtain routine five hours daily of uninterrupted sleep during the aide's eight-hour period of sleep.

The patient's assessment does not support the medical necessity for continuous Personal Assistance Service. The patient has Alzheimer's disease and is totally dependent with IADLs (instrumental activities of daily living) and ADLs (activities of daily living). Assessment shows that the patient does not require assistance that cannot be accomplished with a 24 hour live-in PCA (personal care assistant). The sleep observation study shows that a live-in PCA (personal care assistant) would be able to meets the patient's needs and obtain five hours of uninterrupted sleep during an eight hour sleep period. The approved level II, 24 hour live-in PCA (personal care assistant) is sufficient to provide assistance with ADLs (activities of daily living) and personal care for this patient.

The necessity for continuous care has not been met.