Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Alzheimer's disease. 

Treatment: Personal Care Aide (PCA) Level 2 Services of 24 hours per day, 7 days per week (2 shifts of 12 hours of aide services, split shift) for a total of 168 hours per week.

The insurer denied coverage for PCA Level 2 Services of 24 hours per day, 7 days per week (2 shifts of 12 hours of aide services, split shift) for a total of 168 hours per week.

The denial is overturned. 

This is a female patient with a past medical history of dementia, Alzheimer's disease, anxiety and depression. The patient resides in a skilled nursing facility (SNF) and is requesting home care Personal Care Aide (PCA) services as part of her discharge plan from the facility. 

Documentation in the Uniform Assessment System (UAS) report and the insurer's Nighttime Needs form provide sufficient information to determine that the patient's nighttime behavior is incompatible with a live-in aide. On any given night, it is likely that the aide will be in some or all of the following situations at various times each night: providing assistance with activities of daily living (ADLs) (example: transfers, toileting/incontinence care); or trying to sleep and waking up due to patient talking or agitated behavior; or (if there is a bed alarm) wake up abruptly when the alarm goes off to assist the patient; or spend time (as the nurses have been doing in the SNF) to calm the patient and redirect her. Regardless of whether any of these situations are considered "supervision"; it is apparent that the aide will not consistently have adequate sleep.

Considering the patient's history as reported in the UAS, the SNF progress notes, and the advocate's report, it does not appear that a live-in aide can meet the patient's care needs; as it is unlikely that a live-in aide will have 5 uninterrupted hours of sleep per day on a regular basis.

Based on the available information, it is clear that the patient needs substantial assistance with all daily activities, including ADLs that need assistance at variable and recurring times of the day and night. Therefore, it is medically necessary for the patient to have 24 hour PCA services to provide assistance when needed throughout the day and night. 

Although the patient will be discharged to her home, she has been away from home for many months. Due to dementia, it is uncertain whether the patient will immediately recognize her home, or she may possibly be disoriented and confused. If she feels comfortable at home, it is possible her behavior may improve. However, with dementia, changes in environment and living situation may initially result in anxiety and increased behavioral symptoms; and so the full extent of her behavior and the frequency of her day and nighttime care needs will be determined more clearly when she is home.

The following recommendation is based on the records provided for this review, which did not include recent nursing home records. The patient's physician will determine when the patient is medically stable for discharge. The physician and nursing home staff involved in discharge planning will provide the final determination of the safety of the discharge plan including services recommended from this review.

With the understanding that the patient will be medically stable at the time of discharge,
Personal Care Aide Level 2: 168 hours/week; 12 hours x 2 x 7 days, split shift are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Personal Care Aide (PCA) Level 2 Services of 24 hours per day, 7 days per week (2 shifts of 12 hours of aide services, split shift) for a total of 168 hours per week should be overturned. Medical necessity is substantiated.