Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Personal Care Aide (PCA) Services.
The insure denied Increase in Personal Care Aide (PCA) Services: 24 Hours per Day, 7 Days per Week (live-in, per diem). 
The health plan's determination is overturned. 

The patient is a female with a past medical history of dementia, bowel and bladder incontinence, congestive heart failure, and osteoarthritis with leg weakness who had been assigned PCA (personal care assistant) service hours. There was a request to increase PCA hours, and the patient had another assessment tool performed with a noted increase in assistance with the task of eating from supervision to limited assistance, while all other tasks remained the same. Specifically, the patient was assessed at total assistance for tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, walking and locomotion while assessed at maximum assistance with tasks of managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, transfer toilet, toilet use, and bed mobility.

The Increase in Personal Care Aide (PCA) Services: 24 Hours per Day, 7 Days per Week (live-in, per diem) is medically necessary for this patient.
The patient has been assessed with assessment tool on two occasions about 6 months apart indicating the patient needs assistance with tasks of bathing, personal hygiene, dressing upper/lower body, transfer toilet, toilet use and bed mobility all of which occur outside of the time frame when the patient has aide services. Her aide is available from 9 am to 7 pm daily, and the patient also has unscheduled needs of transfer toilet, toilet use, and bathing as she has documented bladder and bowel incontinence. Dementia is a progressive disease with predicted clinical worsening. The patient does not have an informal helper outside of the current PCA service hours, and the family is no longer able to afford the private PCA that was assisting the patient outside of the insurer paid PCA service hours. The PCA service hours are not solely for supervision and safety but to assist the patient with activities of daily living (ADL) both scheduled and unscheduled. The patient is not able to perform incontinence care without assistance hence she would be left in urine and/or stool from 7 pm to 9 am the next day when PCA arrives, putting her at risk for skin breakdown and infection. There is an underestimation of the patient's PCA care needs with transfer toilet, toilet use, and incontinence cares on the assessment tool. PCA services are medically necessary under Medicaid when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in her own home. In addition, medical necessity is defined as medical care and services that are necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person capacity for a normal activity or threaten some significant handicap. The patient's PCA services 24 hours per day (live-in) are medically necessary.