Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment:  Personal Care Assistance Services: 24 Hours per Day, 7 Days per Week - Split Shift (Monday through Sunday), Total of 168 Hours per Week.

The insurer denied  Personal Care Assistance Services: 24 Hours per Day, 7 Days per Week - Split Shift (Monday through Sunday), Total of 168 Hours per Week.  The determination is overturned.

The patient has a past medical history of glaucoma, diabetic retinopathy, hypertension, cardiomyopathy, congestive heart failure, dementia, hyperlipidemia, urinary retention, deep vein thrombosis (DVT), low back pain, diabetes mellitus type 2, dementia, urinary incontinence and bowel incontinence who had underwent a universal assessment via video assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, and toilet use. With the tasks of walking, locomotion, transfer toilet, bed mobility, and eating, the patient was assessed at extensive assistance. Notes from the assessment stated the patient lived alone, had a Mini-Mental State Examination (MMSE) of 5 out of 30, and required insulin 3 times daily. The patient was assigned PCA services 24 hours/day, live-in, 7 days/week.
There was an appeal by the patient and/or her provider requesting personal care assistant (PCA) services 24 hours/day, split shift, 7 days/week. The insurer an sent appeal decision notice denying the request to increase PCA services to 24 hours/day, 7 days/week, live-in. The denial stated there was a request to increase hours because the patient's daughter felt it was not fair to the aides because they had to stay awake sometimes until 2:00 AM and the patient was very often getting up at night and having the aides assist the patient. The denial also stated any extra hours would be for stand-alone safety supervision as there were no additional tasks based on the patient's functional needs.

The patient's primary care physician (or provider) (PCP) provided a letter stating the patient's past medical history including vision impairment requiring assistance with ambulation and due to the patient's dementia and cognitive behavior and medical comorbidities there was a need for 12-hour split shifts for overnight and supervision and assistance with all activities of daily living. The patient had a follow-up visit with ophthalmology and the ophthalmologist provided a letter stating the patient had severe vision impairment and was unable to perform any of her activities of daily living independently. The patient's daughter provided a letter requesting an increase in PCA services to split shift stating the patient's nighttime needs were going unmet, the patient was frequently incontinent of bladder and bowel, the patient's incontinence supplies were changed 4-5 times or more overnight, the patient did not have the ability to turn or change her position, the current aides were turning and repositioning the patient every 2-3 hours to prevent bedsores, and due to the patient's poor health and declining cognitive condition the patient did not sleep through the night as the patient did not cognitively recognize it was nighttime. The daughter further states the current aides were unable to obtain 5 hours of uninterrupted sleep. Lastly the letter stated adaptive or specialized equipment or supplies could not meet the patient's needs and the patient had no voluntary informal caregiver able to provide assistance.
At issue is the medical necessity of Personal Care Assistance Services: 24 Hours per Day, 7 Days per Week - Split Shift (Monday through Sunday), Total of 168 Hours per Week medically necessary for this patient.

Yes, the services are medically necessary. The patient is blind, has documented worsening cognitive and functional status as per her medical providers and daughter. The patient requires at least extensive assistance with all activities of daily living (ADLs) although her medical provider and daughter assert that her assistance needs are higher for bed mobility, transfer toilet, and toilet use and the assessment underestimated the patient's care needs. The daughter documents that the patient is being turned and repositioned every 2-3 hours. The daughter also documents that the patient requires a diaper change 4-5 times overnight due to urinary and bowel incontinence. The patient has unpredictable and unscheduled care needs that span a continuum of time, and the insurer did not document a plan to meet these unpredictable and unscheduled care needs specifically in the overnight hours. The patient's care needs as documented by her daughter in the overnight hours, are such, that a PCA would be unable to obtain at least 5 hours of uninterrupted sleep. Due to the patient's medical diagnosis of dementia, the patient experiences wakefulness in the overnight hours and requires assistance with ADLs during that time. The patient does not have informal help to assist in the overnight hours. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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.