Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease
Treatment: Personal care aide (PCA) two 12 hour split shifts per day, 7 days a week
The insurer denied the PCA two 12 hour split shifts per day, 7 days a week.
The determination is upheld.

The patient has a past medical history of diabetes mellitus type 2, dementia, osteoporosis, anxiety, rheumatoid arthritis, osteoarthritis, glaucoma, gastroesophageal reflux disease (GERD), and atrial fibrillation on chronic anticoagulation who had been assigned personal care assistant (PCA) services 8 hours/day, 7 days/week based on a telephonic assessment. The tasking tool estimated 35 hours/week. The patient had another assessment, in person, following a fall with injury.

Due to a significant change in status the patient did have another assessment performed assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of stairs and transportation. The patient was assessed at extensive assistance with tasks of managing medication, phone use, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at supervision 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 and a deterioration of overall self-sufficiency in the last 90 days. The insurer sent an initial adverse determination denial notice denying request to increase PCA services. The denial stated the patient was referred to physical therapy and was participating, the plan recommended splitting current PCA services to cover her daytime and nighttime needs and giving more than 8 hours did not prevent falls or injuries.

The insurer sent a final adverse determination denial notice continuing to deny request to increase PCA services stating the patient did not meet criteria and the request was not medically necessary. The patient's medical provider appealed denial decision. The patient's daughter sent a letter stating the patient had significant deterioration in her health, the patient had lost 20 pounds recently, the patient had frequent falls, and the patient's daughter is unable to provide informal support. The patient's medical provider sent a letter stating the patient was homebound, the patient was unable to perform basic functions of living, and the patient had polyuria and nocturia and required help with the toilet regardless of day or night and the patient had a history of multiple falls when left unassisted and trying to do it herself. The provider letter stated it was in their opinion a safe and appropriate health care regimen would be split shift of 12 hours and 12 hours a day 7 days a week. The patient's neurology provider sent a letter stating the patient had a fall with subdural hematoma and since her last admission to the hospital the patient had significantly deteriorated in terms of her memory and cognitive status. The provider also noted due to the patient's history of falls, subdural hematoma, and significant cognitive decline the patient was judged not to be safe home alone. The provider also stated the patient required around-the-clock supervision and assistance and the patient would not know to call 911 and an emergency. In addition, the provider noted the patient did not know which medication she is supposed to take and when and the patient requires constant supervision and reminders.

At issue is the medical necessity of personal care aide (PCA) two 12-hour split shifts per day, 7 days a week.

The services are not medically necessary.

Although there is documentation of the patient's worsening physical and cognitive functioning, there is no documentation of medical necessity of overnight care needs that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. In addition, there is no documented overnight care logs demonstrating the specific assistance needs in the overnight hours that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The patient's medical providers have also not documented medical necessity of turning and repositioning every 2 hours, nor other frequent care needs. 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 two 12-hour split shifts per day, 7 days a week are not medically necessary for this patient.