Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral infarction; dementia; chronic pain

Treatment: Personal Care Aide Level 2:  12 hours per day, 7 days per week, for a total of 84 hours per week

The insurer denied coverage for Personal Care Aide Level 2:  12 hours per day, 7 days per week, for a total of 84 hours per week. The denial is reversed. 

This patient is a male has extensive medical history and severe functional impairment. He requires assistance for all daily activities. The advocate's appeal report indicates that due to health problems the patient's wife no longer resides at home, so the patient lives alone. His primary source of assistance is from PCA services, currently approved for 56 hours per week. As per the, one of his children provided some assistance.  The advocate's report indicates that none of the patient's children live close to the patient to be able to provide support. External appeal is requested for increase of PCA hours. As per the UAS, the patient is dependent on caregivers for all IADLs (total dependence or maximal assistance) and all ADLs (most are total dependence or maximal assistance, except eating: extensive assistance). The patient's functional impairment is due to cumulative effect from several medical conditions including: cerebral infarction, chronic pain, and dementia.
The patient needs maximal assistance for bed mobility; which is > 50% weight-bearing support. As per notes in the UAS, patient has increased weakness, upper extremity joint pain and decreased ROM. It is unlikely the patient is able to effectively re-position himself during the hours he is in bed each day. It is not known whether the patient has any type of pressure relief mattress or overlay on his bed; but even if this is in place, this does not eliminate the need for repositioning. One reason a caregiver needs to be present is to reposition the patient for comfort. If the patient has pain while in bed due to poor positioning or uncomfortable limb placement for prolonged periods, he has very limited ability to properly reposition himself. It is noted in the UAS that the patient needs significant support to sit up in bed; and so it appears he has difficulty sitting up to drink fluids, which may increase risk of dehydration if he has no fluids for 16 hours.

Based on the patient's severe functional impairment as described in the UAS, the patient is unable to sit up in bed, transfer out of bed, walk, or use a wheelchair without substantial assistance. Due to his immobility, it is less likely that he would fall.  However, there is potential for harm when the patient is alone for so many hours. If the patient attempts some movement in bed, or tries to get out of bed when he is alone (possibly due to confusion/disorientation at night due to dementia), he may slide/fall off the bed, which can result in injury. Side rails can be dangerous when used as a restraint to keep someone in bed, especially for a person with dementia, as injuries can occur with side rails. 

The request for increase of PCA hours is for 84 hours per week (12 hours per day, 7 days per week). The patient needs a high level of assistance for all IADLs and ADLs; including the need for assistance at night. This raises a concern as to how the patient can receive the necessary care for toileting/incontinence and bed mobility (repositioning) during the 12 hours when he would still be alone.

Based on the above, the medical necessity for the Personal Care Aide Level 2: 12 hours per day, 7 days per week, for a total of 84 hours per week is substantiated.  The insurer's denial is reversed.