Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia, Osteopenia, Delirium secondary to Hyponatremia.

Treatment: Personal Care Aide level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift), total of 168 hours per week.

The insurer denied coverage for Personal Care Aide level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift), total of 168 hours per week.

The denial is overturned.

This is a female patient with multiple medical conditions (including Alzheimer's dementia and osteopenia) and substantial functional impairment. She lives alone and needs assistance with all daily activities. She was hospitalized with delirium caused by severe hyponatremia and developed significant mental and physical decline as a result. The patient was approved for personal care aide (PCA) services 38.5 hours per week. The patient (via designee) requested an increase of PCA services to 24 hour split shift which was denied.  

The patient was hospitalized with delirium caused by severe hyponatremia. Dementia/cognitive impairment is a significant cause of functional decline in older people, with gradual loss of ability to perform daily activities as dementia progresses. It is not unusual for people with dementia who are hospitalized to develop acute mental status changes (delirium). Symptoms from delirium usually improve when the acute cause of delirium resolves; but for a person with dementia, it is not unusual for new cognitive deficits to occur and persist. Based on the patient's daughter's report of the patient's cognitive ability before and after hospitalization, it appears there has been a significant change. A recent decline in cognition has had a significant adverse effect on the patient's functional status for daily activities.

The patient is totally dependent for housework, and needs maximal or extensive assistance for other instrumental activities of daily living (IADLs); except phone use (setup help). For most activities of daily living (ADLs), the patient needs extensive assistance; except for toilet use (limited assistance), bed mobility (supervision), and eating (independent, setup help). The patient's functional status has declined as the daughter indicates the patient needs total assistance with all aspects of toileting, and she needs assistance with bed mobility and eating. Her current functional status appears to be the result of chronic diseases exacerbated by recent events. Following an acute illness, improvement can be a slow, gradual process, and the patient may not return to the previous level of function. 

The patient needs extensive assistance for transfers and walking. She has multiple risk factors for falls, including: arthritis, chronic pain, dizziness, unsteady gait, advanced age, cognitive impairment, a history of falls, and use of medications associated with falls. Shortly after returning from the hospital, the patient fell when she attempted to use the commode without assistance. 

As per NYS regulations for personal care services, in order to qualify for a live-in aide, the patient's personal care needs should be sufficiently infrequent that an aide can obtain on a regular basis 5 uninterrupted hours of sleep during the aide's 8 hour period of sleep. Based on activity logs provided by the patient's daughter, the patient's need for ADL assistance is not compatible with a live-in aide; and so the best plan of care for the patient is to provide PCA 24 hour continuous services, i.e. split shift. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for PCA level 2: 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift), total of 168 hours per week is substantiated. The insurer's denial is overturned.