Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia.
Treatment: Increase in Personal Care Aide (PCA) Services -
12 hours per day, 7 days per week (Total amount of 84 hours per week)
The insurer denied the request for an increase in Personal Care Aide (PCA) Services - 12 hours per day, 7 days per week (Total amount of 84 hours per week).  
The insurer approved 5 hours per day, 7 days per week, total of 35 hours per week.
The denial is overturned.

The patient is an senior female with a history of Alzheimer's dementia, coronary artery disease and urinary incontinence.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  An appeal review has been requested for an increase in Personal Care Aide (PCA) Services - 12 hours per day, 7 days per week (total amount of 84 hours per week) to provide for increased activity of daily living (ADL) support.

Yes, the requested increase in Personal Care Aide (PCA) Services - 12 hours per day, 7 days per week (total amount of 84 hours per week) is deemed medically necessary.

This is a senior female with a history of Alzheimer's dementia, coronary artery disease and urinary incontinence.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  Although an assessment of the patient's functionality and ability to perform activities of daily living (ADLs) was completed and reported that the currently approved plan of 35 hours/week of personal assistance services is sufficient to meet her current needs, the patient's advocates relate that this reduced schedule leaves her home alone, completely unassisted for numerous hours a day.  This is problematic as she requires assistance for the completion of the majority of her activities of daily living (ADLs) including bed mobility, repositioning, transfers, ambulation, toileting, dressing, bathing, eating, shopping and transportation.

There is a letter from the spouse's physician noting that he is actively being treated for multiple myeloma in addition to multiple other chronic medical conditions, and is often fatigued and has pain.  For these reasons, he can no longer provide the ongoing care needs that the patient requires including help with the majority of her activities of daily living.  Additionally, there is another letter from the patient's physician from early 2021 noting an increase in balance problems as well as a fall the patient suffered at home. Due to safety concerns, she also recommended an increase in hours.  Overall, the current plan approved 35 hours/week is insufficient to meet the patient's needs.

Hence, provision of Increase in Personal Care Aide (PCA) Services -12 hours per day, 7 days per week (total amount of 84 hours per week) can reasonably be expected to be beneficial for the patient and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely.   For these reasons, the increase in Personal Care Aide (PCA) Services - 12 hours per day, 7 days per week (total amount of 84 hours per week) is deemed medically necessary.