Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's disease
Treatment: Increase in personal care services to 12 hours (hrs) a day, 7 days a week
The insurer denied Increase in personal care services to 12 hours (hrs) a day, 7 days a week.
The determination is overturned.

This is a female patient with a history of Alzheimer's disease, vascular dementia, generalized osteoarthritis, vasovagal syncope, dyspnea, trigeminal neuralgia, and urinary incontinence. The patient was previously approved for 8 hours per day of personal care assistant (PCA) services (56 hours per week). The patient and her care team requested 12 hours per day of PCA services (84 hours per week).
The patient's primary care physician (or provider) (PCP) wrote a letter of support. The letter states that the patient needs assistance with transferring, bathing, toileting, grooming, and dressing and needs support with medication use, housekeeping, technology use, shopping, and meal preparation.
A video Uniform Assessment System (UAS) was completed. Per the UAS, the patient lives with her daughter. The patient fainted in the bathroom and her daughter was able to hold her and brought her body down to the bathroom floor. The assessor reported that the patient needs help to change pull ups. A tasking tool was used to determine that the patient receive 57 hours per week of PCA services.
The patient's daughter wrote a letter of support; per this letter, her mother is unable to use the toilet or change her pull up on her own. The letter states that the patient has fainted numerous times on the toilet due to vasovagal syncope, and toilet use is a known trigger of syncope for her. Her daughter currently provides an average of 10 hours per day of unpaid care. The patient's daughter is planning to undergo spine surgery and will be unable to assist the patient as much as she currently does while she recovers from surgery. 
Per her neurology family nurse practitioner (FNP), the patient requires assistance with undressing, dressing, bathing, grooming, and personal hygiene. 
 At issue is the medical necessity of increase in personal care services to 12 hours (hrs) a day, 7 days a 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, 12 hours per day (84 hours per week) of PCA services is medically necessary.
There is documentation in the UAS that the patient requires at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use and therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The insurer should not have utilized a tasking tool to calculate hours given the patient's assistance with unscheduled and unpredictable care needs. There is documentation from the patient's PCP and neurology provider of the medical necessity of increased PCA services. The patient will not have informal support for the entire time outside of the previously assigned PCA hours. Her daughter will not be able assist her with these needs after surgery due to restrictions in lifting and bending per her surgeon's recommendations. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living (ADLs).