Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Assistance Services, 24 hours per day (split-shift), 7 days per week (Monday through Sunday), for a total of 168 hours per week
The insurer denied the Personal Care Assistance Services, 24 hours per day (split-shift), 7 days per week (Monday through Sunday), for a total of 168 hours per week.
The determination is overturned.

The patient has a past medical history of hypertension, osteoarthritis, urinary incontinence, bowel incontinence, dementia, and hyperlipidemia who had been hospitalized with altered mental status and was diagnosed with sepsis and a urinary tract infection (UTI). The patient had difficulty with swallowing and had a speech evaluation and was put on pureed diet with thin liquid. The patient had a follow up visit with her primary care physician (PCP), noting the patient was homebound and the family was having difficulty with transfers and ambulation. The PCP note stated the patient's son is not able to provide care overnight and the patient's son's girlfriend was not available to provide care. The PCP stated the patient had a hospital bed but may need a Hoyer lift. There was a request to start personal care assistant (PCA) services for the patient and the patient underwent an assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, shopping, and equipment management, while maximum assistance with tasks of managing medication, phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, transfer toilet, and toilet use. The patient was assessed at extensive assistance with task of eating and limited assistance with tasks of walking, locomotion, and bed mobility. Notes from the assessment stated that the patient had severe cognitive impairment, required weight bearing assistance with all activities of daily living (ADLs), and lived with a grandson. The plan approved PCA services 77 hours/week. The insurer sent a final adverse determination denial notice denying a request for PCA hours at 24 hours/day, split-shift, 7 days/week. The denial noted that the daughter had requested an increase in PCA services as there had been a change in the family living situation and the patient no longer had a caregiver at night. The denial stated an increase in PCA hours was not provided for safety supervision alone. The denial stated the patient's personal care tasks could still be done in the time that had been provided and the hours per week are enough to support the patient's current ADLs: walking, locomotion, transfer toilet, toilet use, eating, bathing, personal hygiene, and dressing upper/lower body. The denial further stated the patient has no nighttime needs with no medical need for frequent nighttime changing or incontinence products. The patient had a physical therapy (PT) visit, noting ongoing services and patient was not able to utilize a wheeled walker due to her cognition and had a stage 1 pressure ulcer on her right lateral buttock. At issue is the medical necessity of Personal Care Assistance Services, 24 hours per day (split-shift), 7 days per week (Monday through Sunday), for a total of 168 hours per week.

The services are medically necessary. The patient has a documented decline in physical and mental functioning following hospitalization. The patient no longer has informal help as her grandson is working at night and his girlfriend moved out. The patient requires assistance with all ADLs/Instrumental activities of daily living (IADLs). The patient has incontinence of bladder and bowel with the need to reposition and change chux or diapers. The patient's PT notes indicate the patient has a stage one pressure sore. The patient had documented loss of functional ability with transfers and ambulation and the patient's PCP recommended a Hoyer lift if the patient was unable to improve with PT services. The patient has unpredictable and unscheduled care needs that span a continuum of time. The patient has 24 hour care needs, therefore, the universal assessment tool should not have been utilized to calculate PCA service hours. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's care needs cannot be met with medical supplies and equipment alone. 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, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.