Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertensive heart disease without heart failure, coronary heart disease, hyperlipidemia, dementia with behavioral disturbance

Treatment: Personal Care Assistance Level II, 9 hours per day, 5 days per week (Monday through Friday), and total of 45 hours per week

The insurer denied coverage for Personal Care Assistance Level II, 9 hours per day, 5 days per week (Monday through Friday), and total of 45 hours per week. The denial is reversed. 

This patient is a female who lives at home with daughter. The patient has substantial functional impairment and needs assistance for most daily activities. She receives personal care assistance (PCA) 35 hours per week (7 hours x 5 days). Daughter provides care when aide is not present. Request was made for PCA services 45 hours per week (9 hours x 5 days), which was denied. An external appeal was requested.
The patient has dementia (Alzheimer's disease, as per physician's letter). The available records indicate the patient has significant cognitive impairment. For a person with dementia, decline of ability to perform daily activities is an expected consequence of the disease, with increasing functional impairment as dementia progresses. The UAS reports patient's cognitive status for decision making as minimally impaired with cues or supervision needed in specific situations when decisions become unsafe. However, other information in the UAS describing the patient's mental status and ability to perform daily activities appears to indicate more advanced cognitive impairment. It is noted patient has impaired short term and procedural memory; oriented only to person; cannot direct care. Mental status is noted as confused, impaired judgment, poor insight. The patient has history of wandering.

The UAS indicates significant functional impairment. For IADLs, The patient needs maximal assistance for finances and medication management, which typically require a higher level of cognitive function. She needs extensive assistance for phone use; also suggesting impaired cognition. For all housekeeping related tasks, patient needs maximal assistance or total dependence. Regarding ADLs, in addition to needing physical assistance for most ADLs, the nursing notes indicate patient needs direction, verbal cueing, reminders, prompting, and supervision to complete personal care tasks. It appears the patient can no longer perform most daily activities (ADLs and IADLs) without assistance.

The need for a caregiver throughout the day for this patient is not for safety supervision alone. As a result of the patient's cognitive impairment and various other physical symptoms and functional limitations, the patient needs assistance with most daily activities including ADLs that occur at multiple and unscheduled times of the day (i.e. walking, transfers, toileting); and so it is medically necessary for a caregiver to be present throughout the day to provide assistance with ADLs.
Personal Care Assistance Level II, 9 hours per day, 5 days per week (Monday through Friday), and total of 45 hours per week is medically necessary. The health plan did not act reasonably in the best interest of the patient.

Based on the above, the medical necessity for the requested Personal Care Assistance Level II, 9 hours per day, 5 days per week (Monday through Friday) for a total of 45 hours per week is substantiated.  The insurer's denial is reversed.