Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: PCA (personal care aide) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week
The insurer denied coverage for PCA level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week.
The denial is overturned.

According to the documentation submitted, this is an adult with a history of heart disease, diabetes, dementia, hypertension, anemia, gastroesophageal reflux disease (GERD), hyperlipidemia, hypothyroidism, peripheral vascular disease (PVD), and osteoarthritis. Per the Uniform Assessment for New York (UAS-NY), the patient lives alone in a private residence. The patient is alert and oriented (A+O) x 1. The patient is incontinent. The patient needs assistance with many activities of daily living (ADL's). 

The insurer has denied coverage for personal care aide (PCA) level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week, as not medically necessary. In a Final Adverse Determination letter they stated that the plan approval stays at PCA 66.5 hours per week. The two most recent assessments were reviewed. The patient's ability to perform daily activities stayed the same for many ADL's (activities of daily living). The patient's needs can be met with 66.5 PCA (personal care aide) hours a week. 

According to the medical records, the patient has dementia. The patient is minimally ambulatory and requires full assistance to stand as well as to walk and toilet. The request is for 84 hours. The patient lives with their son independently per records, but the assessment states the patient lives alone. The patient eats mainly soft and pureed foods. The patient is incontinent of bowel and bladder.

Personal care aide (PCA) level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week is considered medically necessary for this patient. As stated above the patient has dementia and is minimally ambulatory and requires full assistance to stand as well as to walk and toilet.  The patient lives alone, is incontinent of bowel and bladder, and needs help with activities of daily living.  Therefore, 84 hours are necessary.

"Dementia refers to a clinical syndrome characterized by progressive cognitive decline that interferes with the ability to function independently. Symptoms of dementia are gradual, persistent, and progressive. Individuals suffering from dementia experience changes in cognition, function, and behavior. The clinical presentation of dementia varies greatly among individuals, and the cognitive deficits it causes can present as memory loss, communication and language impairments, agnosia (inability to recognize objects), apraxia (inability to perform previously learned tasks) and impaired executive function (reasoning, judgement and planning)" (1).

"Home care (HC) workers provide essential health and personal care supportive services that enable people to live at home rather than receive care in a nursing home or other facility. The great majority of those who receive HC are people over age 65 years, as well as those of all ages with illness or disabilities" (2).

"While family caregivers have traditionally provided care for older adults with chronic conditions and disabilities, the demand for paid home care workers has increased in the last decade. Although typically thought to assist with personal care, emerging data suggest that paid home care workers assist with a wider scope of care. However, the extent and quality of the care they deliver remains poorly understood" (3).                                                         

Based on the above, the insurer's denial of personal care aide (PCA) level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week must be reversed. 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: 12 hours per day - 7 days per week - for a total of 84 hours per week is substantiated.