Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia
Treatment: home health care
The insurer denied Personal Care Aide (PCA) Level 2 Services: 7 Days per Week, 12 Hours per Day (Split Shift) - Total of 168 Hours per Week . The health plan's determination is overturned. 

The patient is a female with past medical history of advanced Alzheimer's dementia with behavioral disturbance, coronary artery disease, ataxic gait, hypertension, hyperlipidemia, bilateral presbycusis with hearing loss, mixed urinary incontinence, bowel incontinence, and osteoarthritis who had been assigned PCA (personal care aide) services assessing the patient at total assistance with tasks of ordinary housework and shopping while maximum assistance with tasks of meal preparation, managing finances, managing medication, and stairs. With tasks of transportation, bathing, personal hygiene, and dressing upper/lower body the patient was assessed at extensive assistance while limited assistance with tasks of equipment management and toilet use. The patient was assessed at supervision with tasks of walking, locomotion, and transfer toilet while set up with task of phone use and independent with tasks of bed mobility and eating. Notes from the assessment stated the patient had a decline in activities of daily living (ADL) status over the last 90 days as well as a deterioration in overall self-sufficiency in the last 90 days. 

Personal Care Aide (PCA) Level 2 Services: 7 Days per Week, 12 Hours per Day (Split Shift) - Total of 168 Hours per Week are medically necessary for this patient.
There is documentation of progressive decline of patient's dementia with an increased need for assistance with Instrumental activities of daily living (IADL) and activities of daily living (ADL) based on comparison of the assessments. The patient's medical provider has documented medical necessity for an increase in PCA services. The patient's medical provider has also documented the need for toileting and incontinence cares every 2 hours during the day and night to prevent skin issues and infection. The patient is not able to ambulate, transfer toilet, use toilet, or provide incontinence cares without assistance. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The plan incorrectly assumed the patient has informal help outside of the currently assigned PCA services which is not true as the patient's daughters do not live locally. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Dementia is a progressive illness with anticipated increase in assistance needs as time does go by. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7 days/week, split shift, 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.