Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Osteoarthritis

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split-shift) - a total of 168 hours per week

The insurer denied the Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split-shift) - a total of 168 hours per week

The denial was overturned.

This is a female patient who has medical history of coronary heart disease, atrial fibrillation, dementia, depression, insomnia, chronic kidney disease stage 3, hypothyroidism, urinary incontinence, osteoporosis, wedge compression fracture first lumbar vertebra, osteoarthritis, spinal stenosis (lumbosacral), and vitamin deficiency
with severe functional impairments.  She lives alone and has been receiving personal care aide (PCA) services 84 hours per week. The patient has family but it appears they are unable to provide daily assistance on a consistent basis. Request was made to increase PCA services to 24 hours split shift, which was initially denied. On appeal the insurer increased PCA services to 24 hour live-in. An external appeal was requested for 24 hours split shift services.

Based on the UAS information (with history from the daughter) it appears the patient has substantial cognitive impairment, with severely impaired decision making, extensive memory loss, frequent confusion, easily distracted. It appears her ability to communicate is limited to simple requests and responses. For a person with dementia, loss of ability to perform daily activities is an expected consequence of the disease as it progresses. In earlier stages of dementia, loss of ability for IADLs usually precedes ADLs, as IADLs generally require higher level of cognitive function. The patient is totally dependent for IADLs. Regarding ADLs, in later stages of dementia the affected person may not remember, recognize or know what to do for basic daily activities.

The patient has h/o chronic pain due to osteoarthritis and spinal stenosis. As a result of a fall and a left femur fracture the patient fractured L1 vertebra. She also has h/o. The patient has osteoporosis, and so falls are high risk for additional fractures. The patient has been treated with various pain medications, with some adverse effects from several (noted in physician's records). She is currently using fentanyl patch and Tylenol prn; efficacy is not clear. It is likely that pain is a significant factor in the patient's extremely limited ability to participate in ADLs (all ADLs need weight-bearing assistance).  Arthritis is a frequent cause of pain and disability in older people. In later stages of dementia, pain may not be communicated with verbal expression of pain.

The patient is completely dependent on caregiver assistance for toileting and incontinence care. As per the nighttime logs, the patient needs to use the toilet or needs incontinence care several times at night. When possible, the patient is assisted to the toilet; but when incontinence occurs, then prompt incontinence care is needed. The patient is at risk for skin injury due to incontinence, including dermatitis, fungal infection, and increased risk of pressure ulcers. It is also a source of discomfort for the patient and if no assistance is available, she may try to get out of bed. 
Her current functional status requires substantial assistance for all daily activities, including ADLs that can occur and need assistance throughout the day and night (i.e. transfers, mobility out of bed, toileting, incontinence care, bed mobility/repositioning in bed).

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split-shift) - a total of 168 hours per week is substantiated.  The insurer's denial is overturned