Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Visual loss, Physical impairments.
Treatment: Personal Care Aide (PCA) Level 2 services at 24 hours per day (split shift), 7 days per week for a total of 168 hours per week
The insurer denied coverage for Personal Care Aide (PCA) Level 2 services at 24 hours per day (split shift), 7 days per week for a total of 168 hours per week.
The denial is overturned.

This is a male patient with a past medical history of atherosclerosis, hypertension, carotid stenosis, chronic right sided low back pain without sciatica, glaucoma, traction detachment of retina, peripheral arterial disease, type 2 diabetes mellitus, foot wound, confusion, and dementia with behavioral disturbance. A Uniform Assessment System (UAS) report was done. The patient lives alone in a one bedroom apartment on the first floor of an apartment building which requires stairs to access his home. The patient reported he is confused and disoriented, and he needs to be redirected by his caregivers.  

The patient is totally dependent for meal preparation, ordinary housework, managing finances and shopping. He needs maximum assistance with managing medications, phone use, bathing, and dressing his lower body. The patient needs extensive assistance with personal hygiene, dressing his upper body, walking, locomotion, toilet transfer, toilet use, bed mobility, and eating. He uses an assistive device for locomotion indoors.  The patient requires assistance with his activities of daily living (ADLs) and instrumental activities of daily living (IADLs) due to his dementia, blindness, pain and limited range of motion related to his lumbago with sciatica. An increase to personal care aide: level 2 services at 24 hours per day (split shift), 7 days per week for a total of 168 hours per week, is being requested.

Physician notes indicate that due to dementia, visual loss and physical impairments, the patient needs 24-hour care and assistance. The patient has no informal caregiver during the night. The patient has dementia and was recently admitted with worsening delirium.  The patient can be confused enough to not recognize his apartment. The patient needs help remembering how to do basic ADLs. As per the recent UAS report, the patient cannot be alone. The patient needs more assistance than just observation and cuing.  The UAS and physician findings indicate that the patient has unpredictable and frequent needs. The patient has urinary incontinence and cannot be relied on cognitively or physically to adequately care for himself to prevent skin changes and infection. If he has any need to be out of bed, the patient needs assistance with transfers and ambulation.  The need for 24-hour assistance is established, and 5 hours of uninterrupted sleep cannot be assured. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The plan did not adequately factor in the degree of physical and cognitive impairment and the need for 24-hour assistance for this patient.

The requested Personal Care Aide (PCA) Level 2 services at 24 hours per day (split shift), 7 days per week for a total of 168 hours per week is considered medically necessary for this patient, as noted above. 

The carrier's denial of coverage for the requested Personal Care Aide (PCA) Level 2 services at 24 hours per day (split shift), 7 days per week for a total of 168 hours per week should be overturned. The medical necessity is substantiated.