Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, hypertension, gout, abdominal aortic aneurysm, cerebrovascular accident (CVA)
Treatment: Personal Care Aide (PCA) level 2: 8 hours per day - 5 days per week; 4 hours per day - 2 days per week - for a total of 48 hours per week
The insurer denied coverage for PCA level 2: 8 hours per day - 5 days per week; 4 hours per day - 2 days per week - for a total of 48 hours per week.
The denial is overturned.

This elderly male has experienced functional decline associated with various medical conditions. He needs assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient lives alone in an apartment attached to his son's house. The patient has been receiving personal care aide (PCA) services 8 hours per day, 5 days per week. He receives informal help from family. 

The most recent Uniform Assessment System (UAS) provided for review was done. Functional status report for IADLs indicates patient is totally dependent for ordinary housework, managing finances, shopping; he needs maximal assistance for meal preparation, managing medications, stairs, transportation; independent for phone use. For ADLs, patient needs extensive assistance for bathing, personal hygiene, dressing upper and lower body, walking, locomotion, bed mobility; supervision for transfer toilet, toilet use, eating. Comparison of UAS identifies functional decline over the past year for most ADLs.

Regarding toileting, the UAS reports patient needs only supervision for toilet transfer. However, the UAS indicates patient has difficulty moving to standing position unassisted (sit to stand transfer); and so, the patient probably needs physical support during toilet transfer. When the patient is having difficulty standing up from any type of seat (including the toilet), it is reasonable to expect that the aide provides physical assistance. Falls can occur in the bathroom during transfers; and when elderly people fall in the bathroom, there is greater chance of injury. 

The patient's mobility is unstable. He needs a walker and weight-bearing assistance to walk. The daughter reported patient does not always remember to use his walker (which increases his risk of falling when he is alone). The patient has no choice but to try to move around his home when he is alone to try to complete routine daily activities. The UAS included report of 3 falls (as previously noted, with one back injury); and the daughter reported another fall which resulted in vertebral fracture. The increased frequency of falls associated with symptoms of pain, weakness, fatigue, impaired balance is an alert to caregivers and medical providers that the patient needs additional help with mobility. The need to move around the home occurs at various and usually unscheduled times of the day. It is reasonable to expect that when a caregiver is present to provide assistance, it is less likely the patient will fall.

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 aide (PCA) level 2: 8 hours per day - 5 days per week; 4 hours per day - 2 days per week - for a total of 48 hours per week services is substantiated.