Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) Services 24 hours a day, 7 days a week (split shift)
The insurer denied: Personal Care Aide (PCA) Services 24 hours a day, 7 days a week (split shift)
The denial is overturned.

This patient is an elderly female with a history of dementia. The patient has short-term, procedural, and situational memory loss. The patient reportedly wanders from time to time. She is currently receiving six days (Monday-Saturday) x 7 hour and Sunday x 4 hours of personal care aide (PCA) services. The request is to increase hours to 24 hours a day, seven days a week (split shift). This request is under review.

The requested increase in Personal Care Service to 24 hours a day, 7 days a week, split shift, is medically necessary.

Per the multiple assessments and appeal letters, the patient has a history of anxiety disorder, fecal smearing, hyperlipidemia, polyarthritis, depression, urinary incontinence, wandering and 
dementia. She is alert and oriented x2. She lives in a one-bedroom apartment. The patient has short-term, procedural, and situational memory loss. She needs cueing at every step for a given task. When her PCA (personal care aide) leaves her alone, she begins to cry. The patient also wanders from time to time. The patient is total dependence for shopping, meal prep, ordinary housework and managing finances. She requires maximal assistance with managing medications, telephone use, and 
transportation. The patient requires extensive assistance with weight bearing by one helper, where the helper still performs 50% (percent) or more of subtasks. The patient requires some weight bearing assistance with bathing, personal hygiene, dressing, 
and toileting. She requires pre-pour of medications from others to ensure compliance. She is unable to participate in meal preparations or housekeeping, and she is dependent on others for these tasks. Per the documentation, patient has had two or more falls in the prior days. One fall was while attempting to use the commode. The patient had bruising on her right shoulder and lower back, causing pain. The second fall occurred when the patient rolled out of bed; no injuries were reported. She was seen in an urgent care and had an x-ray done of her shoulder, with no fracture or dislocation noted. Specifically,  some months ago, the patient fell in her bedroom, because she tried to use the commode all by herself. The next week, she fell from her bed around 1:30am. Her daughter has a camera installed in her mother's home, so she went to her mother's home around 3 AM. During both fall incidents, the patient was unable to get up after the fall and did not use PERS (personal emergency response system) or call 911, which may be due to her cognitive decline from dementia. The patient had a third fall. Her daughter suspects that her mother rolled off the bed, suffering facial, bruising and limited range of motion in her right arm. The patient's sister used to provide informal support, but she is elderly and ill and can no longer assist. The patient's daughter also has her family/professional obligations and can also no longer provide care. The patient is requiring more assistance with all of her ADLs (activities of daily living). The patient is also requiring more assistance with phone use, stairs, transportation, walking, locomotion, and bed mobility. The patient often uses the bathroom/ commode in her bedroom at night, as she does not like sleeping in a wet diaper, and she needs assistance to have it changed if she soils or wets her diaper. The patient's daughter has kids that she has to do homework with and take to school. There are days when the patient refuses to eat, because it is too early, and the aide has to leave by 7pm. The patient's daughter ends up leaving a snack on the table for her mother to eat for when she is hungry at night. There are nights where due to patient's medical condition, she becomes agitated and refuses to 
wash up. She prefers to eat dinner at 8 pm. She has to take her medication with dinner, and she usually goes to bed around 9 pm to 9.30 pm every night. Based upon this information, the request for increase in Personal Care Aide (PCA) Services 24 hours a day, 7 days a week (split shift) is considered medically necessary.