Appeal type: Medical necessity
Decision: Overturned

Diagnosis: type 2 diabetes mellitus, diabetic polyneuropathy, Alzheimer's dementia,  a thoracic spine fracture, hypertensive heart disease, peripheral artery disease, major depressive disorder, joint pain and osteoarthritis
Treatment: Personal care aide (PCA) level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week
The insurer denied coverage for personal care aide (PCA) level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week
The denial is overturned

The patient has unstable gait that has worsened.  After a few steps with rollator, patient is weak, tired and unstable on her feet.  She is unable to take more than a few steps without risk of falling.  She is reliant on home health aide for most daily activities. When she has attempted to do things on her own, she has had multiple falls.  Falls occur in the evening/night after the aide's shift has ended.  She is unable to get up herself and has been found by the daughter, or by the aide on arrival for the next shift.  There have been many instances when the patient has been in bed for hours in soiled bed as she has been unable to go to commode or bathroom. The patient recently developed severe right leg swelling due to extensive blood clot. Patient was started on blood thinner which she well need for months and possibly the rest of her life. The patient needs 24 hour care to assist with all activities of daily living.

The patient has some behavioral problems related to dementia, including yelling for no apparent reason, agitation when alone, curses the aide at times.  The UAS indicates patient has delusions and hallucinations.  Management of behavioral issues associated with dementia is challenging, as many of the medications used to manage these behaviors have variable efficacy and significant side effects.  The patient takes risperidone; efficacy is not known.  She also takes memantine which is indicated for cognitive decline associated with some types of dementia. It also has some benefit in the management of some behavioral problems associated with dementia.

The records provided for review indicate the patient needs assistance for toilet transfer, toilet use, incontinence care, transfers and walking.  The patient has had multiple falls recently when attempting to get up from bed unassisted.  The patient is at high risk for adverse health and safety events, including skin damage due to incontinence, and recurrent falls and injury.  The records indicate the patient needs assistance with toileting related tasks and out-of-bed mobility at night with such frequency, that it is unlikely a live-in aide can have 5 uninterrupted hours of sleep on a regular basis.  During daytime hours, the aide has even more responsibilities including all daily routine Activities of Daily Living (ADLs), meals, and other Instrumental Activities of Daily Living (IADLs), plus assistance for toileting and mobility during the day; and so 5 uninterrupted hours of daytime sleep for the aide is not realistic.  Therefore, it is medically necessary and in the patient's best interest to have continuous PCA services 24 hours per day, split shift.

Personal Care Aide Level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) - total of 168 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is reversed. Medical necessity is substantiated.