Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other - Dementia
Treatment: Personal Care Aide live-in 24 hours per day, 7 days per week
The health plan denied: Personal Care Aide live-in 24 hours per day, 7 days per week
The determination is: Overturned

The patient is a female with medical history notable for dementia and coronary artery disease. The patient is approved for 8 hours per day, 7 days per week (56 hours per week) of personal care aid (PCA) services. The patient and her care team requested an increase to 24 hours per day live-in personal care aid, 7 days per week, and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has been having rapidly deteriorating mental and physical health over the recent months since a prolonged hospitalization and rehabilitation stay after recurrent falls at home. She is mostly bed bound and requires assistance for transfers and activities of daily living. The physician states that additional hours are necessary to prevent further falls and skin injury.
The patient's psychiatric nurse practitioner provided a letter of support for this appeal. The letter states that the patient has neurocognitive disorder, neuroleptic-induced parkinsonism, and dementia with a moderate to severe cognitive deficit. She has aphasia and recent and remote memory loss. Her judgment and insight are poor. Due to these deficits, the provider recommended 24-hour care for the patient as she is not adequately able to direct her care.
A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted after discharge from the nursing home facility after her recent hospitalization. The patient lives alone in her apartment. Cognition was noted to be impaired; she was alert and oriented to person and place only. The assessment states that she is self-directing and can make her needs known but becomes disoriented at times. For her functional status, she requires maximal assistance for meal preparation, housework, and shopping. She requires extensive assistance for finances, medications, phone use, stairs, and transportation. For her activities of daily living, she requires extensive assistance for bathing and dressing her lower body. She requires limited assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. She is independent for bed mobility. She is occasionally incontinent of urine, less than daily. She is continent of stool. She uses Pull-Ups for bladder incontinence at nighttime. During the assessment, she was observed ambulating with a slow and unsteady gate with the assistance of a walker and support person nearby. A task tool associated with the assessment recommended 6.5 hours per day to address her personal care needs.
At issue is the medical necessity of Personal Care Aide live-in, 7 days per week.
The health plan's determination of medical necessity is overturned in whole.
The requested health service of Personal Care Aide live-in 24 hours per day, 7 days per week is medically necessary for this patient.
The patient has moderate to severe dementia, and her care team does not feel that she can adequately direct her own care. She also had a physical decline after a recent prolonged hospitalization secondary to falls. Her falls are evidence of unmet personal care needs, and it is likely that the UAS underestimates her true need given that she was noted to ambulate without assistance, but this has led to falls in the past. She will require assistance with toileting, which will be an unscheduled and continuous personal care need. Her medical team has also attested to the medical necessity for an increase in personal care aid hours to address her needs. Failure to provide for these personal care needs could result in additional falls and associated injuries.