Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase in personal care aide (PCA) hours from 5 days/week, 8 hours/day to 6 days/week, 12 hours/day
The insurer denied an increase in PCA hours from 5 days/week, 8 hours/day to 6 days/week, 12 hours/day.
The determination is overturned.

The patient has cognitive impairment, progressive dementia, chronic kidney disease, osteoarthritis, hearing impairment, coronary artery disease and recurrent falls.

An office note states that he currently receives 8 hours while at home, 5 days/week, but with ongoing declining health (dizziness, weakness, poor balance, and severe coronary artery disease [CAD] with exertional dyspnea) he has a new need for home care, 12 hours/day, 6 days/week. The office note comments on several near falls. The notes report that the patient made minimal gains over 14 skilled physical therapy (PT) sessions. The patient demonstrated cognitive limitations and impulsivity. He requires constant supervision and close guarding to prevent falls. Due to cognitive disability, the patient demonstrates poor carryover and is unable to recall cues given by PT for balance and safety. PT states he requires supervision at all times to prevent injury. No further gains were expected through the utilization of PT.

A Uniform Assessment System-New York (UAS-NY) was done recently  and his cognition is moderately impaired. He has had wandering. He has been resistant to care at times. He requires maximal to extensive assistance with most activities of daily living (ADLs). Eating is supervised only. A decline in ability was noted at a 90-day reassessment. Self-sufficiency has deteriorated. The patient requires maximal assistance or is totally dependent with his instrumental activities of daily living (IADLs). He is frequently incontinent of urine, intermittently incontinent of stool and has limitations with hearing and vision.

The patient was receiving personal care aide (PCA) hours 5 days/week, 8 hours/day. A request was made to increase this to 6 days/week, 12 hours/day.

According to information provided by the insurer, the plan approved a partial increase in services to 48 hours over 6 days. Prior to this the patient was receiving PCA services 3 days/week, 8 hours/day and Consumer Directed Personal Assistance Services (CDPAS) 16 hours over 2 days.

The plan declined providing the requested hours in total due to a review of the patient's care needs and assumed time requirements based off of this and a tasked based tool. It mentions several other tasks the patient is able to perform. It comments on the patient's need for verbal instructions and cueing. The letter comments on monitoring by the patient and comments on the need for constant supervision.

The plan cites the New York state Department of Health (NYS DOH), stating that personal care services are only authorized for personal care tasks and not specifically allotted for safety monitoring.

The plan notes concern for conflict of interest as the patient's family member (daughter) also happens to be the patient's primary care physician (PCP).

A letter is subsequently provided by the patient's daughter outlining her experience and offering corrections/adjustments to some of the determinations made by the insurer.
The patient's daughter argues that at least part of the patient's wandering is to obtain food and not directly because of his dementia. She reports that he does not have patient care services long enough during the day and thus meal preparation after 6 PM is not happening. The daughter is not able to get to his house until 8 PM.

She reaffirms that the patient lives alone. This is supported by other documents but not directly supported by the insurer's letter. The daughter is willing to provide nighttime care, but is requesting daytime care; 6 days a week, 12 hours a day.

At issue is the medical necessity of an increase in PCA hours from 5 days/week, 8 hours/day to 6 days/week, 12 hours/day 

The services are medically necessary. The request for increased services to 6 days/week, 12 hours/day from 5 days/week, 8 hours/day is appropriate. A review of the UAS-NY assessments shows a decline in the patient's physical abilities and an increase in his care needs.

He was noted to have multiple memory problems and be moderately impaired. These notes and PT notes demonstrate that the patient can, in the moment, respond to verbal cueing, but quickly forgets these and reverts to prior unsafe habits.

In this context, the amount of time the patient requires for each task is likely lengthened given the presumed degree and frequency of verbal cueing required.

This is further supported by his decline in ADLs performance, demonstrating maximal or extensive assistance in essentially all domains. He demonstrates a reduction in walking distance. He requires extensive to maximal assistance with toileting and some assistance with bed mobility.

As it relates to IADLs and tasks such as meal preparation, housework, groceries and finances, the patient is essentially totally dependent. Some of these he can rely on family to assist with, but otherwise all in-home tasks during daytime hours required notable assistance. Although the services are not intended for supervision purposes, given the expressed degree of limitations and the need for regular cueing assistance, 12 hours/day would not be unexpected. Further, this assistance, particularly with mobility issues, will enhance safety and reduce morbidity/mortality risks.