Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular Dementia
Treatment: Personal care assistance (PCA) service to 2x12 hour x 7 days/week, split shifts, total 168 hours/week
The health plan denied personal care assistance (PCA) service to 2x12 hour x 7 days/week, split shifts, total 168 hours/week.
The determination is overturned.

The patient has a past medical history of vascular dementia, cerebrovascular accident (CVA), epilepsy, depression, anxiety, second degree heart block, urinary tract infection (UTI), urinary retention, bladder stone, subarachnoid hemorrhage, osteoarthritis (OA), and cervical (C) 5-C6 disk degeneration who had personal care assistance (PCA) hours 5 hours/day, 7 days/week, to total 35 hours/week. The patient was hospitalized following a fall with a diagnosis of second degree heart block and UTI. The patient's physical therapy (PT) notes from the hospital stated the patient required moderate assistance with balance maintenance/weight shifting during ambulation, as well as moderate verbal and tactile cues for limb advancement. The physical therapist noted that the patient was progressing towards goals, however progress was limited by current cognitive status/poor command following. Lastly, the physical therapist stated the patient would require a hospital bed as the patient is maximum assist with bed mobility requiring frequent changes in body position to alleviate pain and the patient would benefit from a gel mattress. The notes also stated the patient no longer has help from her husband due to his own medical issues.

The hospitalist provided a letter stating the patient's diagnoses severely limit her mobility and her ability to complete her activities of daily living (ADLs) and instrumental activities of daily living (IADLs), including dressing, bathing, meal preparation, bathing, and eating, and would benefit from increased home care hours. The patient underwent a telephonic assessment tool assessing the patient at total assistance with meal preparation, ordinary housework, and managing finances while maximum assistance with tasks of stairs, shopping, transportation, bathing, and dressing lower body. The patient was assessed at extensive assistance with the tasks of managing medication, phone use, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at supervision for eating and independent with bed mobility. Notes from the  assessment stated the patient lived alone, was lying in hospital bed, and required assistance with using the walker.

The insurer sent an initial adverse determination denial denying the request to increase PCA services, as the patient's activity of daily living needs were being safely managed at the current number of hours and there were no significant changes in clinical status. The denial also stated the patient lived with her spouse who was involved in her care. The patient's primary care physician (PCP) provided a letter stating the patient's condition has severely deteriorated since her last admission to the hospital. The letter stated the patient was bedridden and needed an elevated level of care. In addition, the letter stated she required full assistance with transfers to the commode at least every four hours and as needed to prevent recurrent UTI. The letter further stated the patient needed complete care with all ADLs. The PCP also stated the patient's husband was not able to provide care to the patient due to his own medical issues, requiring his own increase in PCA hours. Lastly, the PCP recommended increased PCA hours to 24 hours/day, split-shift, 7 days/week. The insurer sent a final adverse determination denial notice, stating the requested increase in PCA hours was not medically necessary and did not meet criteria. The denial stated the patient was receiving shared hours with her husband to total 84 hours/week, which were sufficient to meet her care needs and she had no hands-on overnight needs and providing around the clock PCA services would be excessive and not medically necessary. The denial stated the patient was receiving PT services and according to the report, the patient was able to ambulate up to 30 feet with rolling walker and minimal assistance and was independent with bed mobility. The denial also stated the patient was not bed bound and with assistance was able to stand and ambulate with her rolling walker. In addition, the denial stated the patient did not need hands on assistance with transfers, toileting, ambulation, medications, bed mobility, or meals during the overnight hours. The patent's daughter provided a letter, undated, stating the patient had two admissions to the hospital, one for heart block and UTI and another following a fall at night while trying to use the toilet, admitted with UTI and urinary retention. The daughter noted the patient's mental and physical function declined significantly after each hospitalization. The letter further stated the patient needs one person maximum assistance to get out of bed to commode, can take a few steps to wheelchair with a walker and full support, wears pulls ups but many times is not able to urinate in them and has to be transferred to the commode. The daughter indicated she has her own medical diagnoses, not allowing her to assist in her mother's care fully and works full time. Overnight care logs were provided, noting the patient needed assistance with care at least every 3.5 hours. The patient's advocate provided a letter requesting an expedited appeal of the plan's denial to increase PCA services to 24 hours/day, split-shift, 7 days/week. At issue is the medical necessity of personal care assistance (PCA) service to 2x12 hour x 7 days/week, split shifts, total 168 hours/week medically necessary for this patient.

The services are medically necessary. The patient has documented progressive medical conditions of dementia, osteoarthritis, heart block, and urinary retention. There is documentation from physical therapy in the hospital, the hospitalist, and the PCP that the patient has had a decline in physical and mental functioning since her admission to the hospital. According to the patient's daughter, the patient has had another admission recently with a diagnosis of urinary retention and UTI. The patient has unpredictable and unscheduled care needs over a continuum of time and the insurer did not formulate a plan to address those unscheduled and unpredictable care needs. The patient requires at least some assistance with walking, locomotion, transfer toilet, and toilet use. The patient has no informal support as her husband and daughter are no longer able to provide informal support. The patient's overnight care logs indicate the patient requires assistance with ADL needs at least every 3.5 hours and therefore a PCA care aide would not be able to obtain 5 hours of uninterrupted sleep. The patient's ADL/IADL care needs cannot be met with equipment and medical supplies alone. 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 24 hours/day, split-shift, 7 days/week, to total 168 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.