Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia 

Treatment: Personal Care Assistance (PCA) services, 12 hours per day, 7 days per week

The insurer denied coverage for Personal Care Assistance (PCA) services, 12 hours per day, 7 days per week.

The denial is overturned.


This is an elderly female who has experienced functional decline associated with various medical conditions and needs help with most daily activities. The patient lives alone. Her daughter provided informal support for daily activities in the past, and is still available, but it appears her time is more limited due to work and other family responsibilities. The patient receives help with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) from personal care assistant (PCA) services 5 hours per day, 7 days per week.

Functional status for Instrumental Activities of Daily Living (IADLs): patient was totally dependent for housework; she needed maximal assistance for meal preparation, shopping, transportation; extensive assistance for managing finances and medications, stairs; limited assistance for equipment management; setup help for phone use. For Activities of Daily Living (ADLs), the patient needed maximal assistance for bathing; extensive assistance for dressing lower body; limited assistance for personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use; supervision for bed mobility, eating. 

The physician's office notes indicate the patient has Alzheimer's dementia. Decision making for tasks of daily life was described as minimally impaired - in specific, recurring situations decisions become poor or unsafe; cues/supervision necessary at those times. The patient was oriented to person and place and she had short term memory problem. It was noted that she has periods of confusion and forgetfulness. 

The Uniform Assessment System (UAS) indicated the patient needed extensive assistance with toilet transfer and toilet use (which includes cleaning, clothing adjustment, incontinence care). The activity logs indicate the daughter assisted the patient each time she needed to use the commode, including description of holding the patient under her arms during transfer and cleaning, and assisting with cleaning and changing the diaper.  The patient has impaired mobility with slow, unsteady gait, and episodes of dizziness. 

The patient's mobility is impaired, and she is at high risk for falls. She had two falls that resulted in serious injury and hospitalization. 

The patient needs assistance with dressing and personal hygiene at the start and end of her day. A few of her medications are twice daily and she needs reminders for medications. All meals must be prepared and served, so a caregiver needs to be present for all meals. 

The patient will benefit from PCA services 12 hours per day, which is the time she is most active and needs the most frequent help with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). 

Based on the above, the insurer's denial must be overturned. 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 Assistance (PCA) services, 12 hours per day, 7 days per week services is substantiated.