Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia.
Treatment: Personal care services, level 2- 12 hours per day, 7 days per week, for a total of 84 hours.
The insurer denied personal care services, level 2- 12 hours per day, 7 days per week, for a total of 84 hours.
The determination is overturned.

The patient has a past medical history of Alzheimer's dementia, coronary artery disease, atrial fibrillation, permanent pacemaker status, osteoporosis, hypertension, diabetes mellitus type 2, chronic anticoagulation, and urinary incontinence who was assigned personal care assistant (PCA) services 7 hours/day, 7 days/week, to total 49 hours/week based on assessment. The patient was hospitalized with hypertension. There was a request to increase PCA services and the patient underwent a video assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, phone use, stairs, transportation, bathing, dressing lower body, and toilet use. With the tasks of personal hygiene, dressing upper body, walking, locomotion, and transfer toilet the patient was assessed at extensive assistance while limited assistance with tasks of bed mobility and eating. Notes from the assessment indicated the patient did not have any informal help.
The patient's medical provider documented in a letter the patient's medical diagnoses and a request for split shift services. The provider noted the patient required constant monitoring as her behavior worsens at night, she becomes very aggressive, will try to operate the stove and will try to leave the apartment. Lastly, the provider stated the patient had an unsteady gait and was at a great risk for self injury. Physical therapy was ordered by the provider.
The insurer provided a final adverse determination denial notice partially denying request to increase PCA services with an increase to 56 hours/week. The patient's primary care physician (or provider) (PCP) provided a letter requesting an urgent increase in hours of home care due to the patient's rapidly deteriorating cognitive and physical health and functional status. The provider's letter stated the patient had advanced age, poor functional status, limited range of motion, stamina loss, impaired coordination, and was dependent on a walker for ambulation. In addition, the letter stated the patient had cognitive impairment related to Alzheimer's disease with behavioral disturbances, progressive amnesia, delirium, frequent episodes of disorientation, delusions, history of wandering, major depression, anxiety, chronic insomnia, and anger/agitation especially in the nighttime. The provider also noted the patient had a significant cardiac history, osteoporosis, and osteoarthritis. The provider stated the patient had urinary incontinence and used diapers for which she required multiple daily changing of soiled linens and diapers to preserve skin integrity. Lastly, the provider believed it was very important and medically necessary for the patient to have 12 hours of home care, 7 days/week. The patient's healthcare advocate provided a letter in support of increased PCA services. The patient appealed the denial decision.
At issue is the medical necessity of personal care services, level 2- 12 hours per day, 7 days per week, for a total of 84 hours.

The services are medically necessary. 

There is documentation from the patient's primary care physician (or provider) (PCP) and healthcare advocate of worsening cognitive and physical functioning. The patient's PCP documents the medical necessity of increased PCA services. The patient requires at least limited assistance with all activities of daily living (ADLs) and Instrumental activities of daily living (IADLs), and at least extensive assistance with walking, locomotion, transfer toilet, and toilet use. The patient has 24-hour care needs and therefore a time-based assessment tool should not have been utilized to calculate PCA hours. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The plan assumed that the patient had informal help outside of currently assigned PCA services. The patient has no informal help. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.