Appeal type: Medical necessity
Decision: Overturned

 
Diagnosis: Dementia

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week

The denial is overturned

The patient is diagnosed with Alzheimer's disease, unspecified under hospice care for end stage dementia. The patient lives with their spouse in a 2-bedroom apartment. 

On the Uniform Assessment System New York (UAS-NY) Assessment, the patient's spouse requested an increase because the patient is experiencing weakness and the inability to walk. Based on the assessment the patient's current declines were noted as dressing upper body- maximal assistance; personal hygiene- maximal assistance; walking- total assistance; and locomotion- total assistance. The patient is able to take care of their toileting needs and transfer on and off the toilet with assistance; bathe themselves with assistance; and take medications with assistance from their spouse. The patient's spouse is supportive and involved in the patient's care. The patient has incontinent supplies, gloves, glucometer, Personal Emergency Response System (PERS), cane, shower chair, shower grab bar, bedside commode, walker, wheelchair, and hospital bed in your home that can assist you with your needs. The patient was recently in the hospital for altered mental status and for high blood pressure.

The statement of support for an external appeal for Personal Care Aide services noted that the patient's spouse is frail and weak and can no longer provide for the patient's care need. It was also noted that the patient cannot physically or cognitively assist with toileting needs, transfers on or off the toilet and is dependent on diapers. 

The statement of homebound status noted that the patient is bedbound, non-ambulatory and unable travel to a hearing by any means including public transportation.

Per the cited references, personal care services are the provision of some or total assistance with personal hygiene, dressing, and feeding and nutritional and environmental support. The services must be essential to the maintenance of the patient's health and safety in their home, be ordered by physician or nurse practitioner, and be based on an assessment of the patient's needs for the service in accordance with guidelines. Based on the assessment, the provider's declaration and the statement letter of supporting information the patient will requires additional personal assistance due to the current change and decline in functional status and the inability for the continued care from the primary caregiver. In addition, the patient has had frequent hospital admission due to urinary tract infection (UTI), sepsis and altered mental status, and falls; therefore, additional assistance is supported. Furthermore, the patient cannot physically or cognitively assist with toileting needs, transfers on or off the toilet and is dependent on diapers and is thus at risk for skin breakdown. The need for toileting in view of the patient's deterioration is unpredictable.

As such, the request for Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week is overturned as medically necessary.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week services is substantiated.