Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Dizziness 
Treatment: Personal Care Aide 7 days x (2) 12 hour split shifts 

The insurer denied the personal care aide 7 days x (2) 12 hour split shifts. The denial was reversed. 

This is a female patient with a history of blindness in one eye, glaucoma, shingles, neuropathy, osteoarthritis, osteoporosis, muscle weakness, incontinence, multiple falls, insomnia, gastroesophageal reflux disease (GERD), dizziness, ischemic heart disease, anxiety, depression and a pulmonary embolism. It was reported that the patient had substantial functional impairment, requiring assistance for all instrumental activities of daily living (IADLs) and activities of daily living (ADLs). The patient lived alone and was currently receiving personal care aide services 11 hours per day, 7 days per week.  
Due to the patient's cognitive and visual impairments and weakness, she was unable to independently ambulate safely or self-toilet. It was reported that she had a recent visits to the hospital due to a fall. She required weight-bearing assistance for safe transfers, ambulation and toileting. A request for an increase in personal care services to 7 days a week with two 12 hour split shifts was made. 

According to the Uniform Assessment System (UAS) the patient had chronic pain. The patient had osteoarthritis with pain in the knees that was 9 out of 10 in severity. The patient's gait was noted to be weak and unsteady, and the patient had recurrent falls. The patient needed assistance with transfers and ambulation. Arthritis is a frequent cause of disability in older people, often resulting in dependence on caregivers for daily activities. The patient also had co-morbid conditions, such as fibromyalgia and shingles which could worsen her musculoskeletal strength and stability. The patient took lyrica for postherptic neuralgia and fibromyalgia. The UAS also noted that the patient had left hand pain, which was suspected to be due to neuropathic pain and/or arthritis. This patient's upper extremity pain was likely to restrict performance of many daily activities that require manual dexterity and range of motion of the upper extremity. 

The patient was blind in right eye and had some vision loss on left eye. Vision impairment in older people is significant cause of decreased functional capacity, mood disorders, increased safety risk. Vision loss has an additional adverse effect on people with dementia, as loss of sensory input can increase confusion and disorientation. 

The patient's cognition exam showed impaired short term memory and minimally impaired decision-making capacity. As dementia progresses, loss of ability to perform daily activities is an expected consequence of the disease. It is likely that the patient's total dependence on caregivers for managing finances and medications and using the phone is associated with this patient's cognitive decline. 

Falls in the elderly population are associated with greater risk of serious injuries (e.g. fractures, head trauma), substantial morbidity, and increased risk of death. There are few, if any interventions that can prevent all causes of fall; but assessment can identify those people who are at greatest risk in order to develop a plan of care for fall prevention. For this patient, she needed weight-bearing assistance for safe transfers, ambulation and toileting. The patient had physical, cognitive and sensory impairments that placed her at high risk for falls. The presence of a caregiver during night hours (in addition to daytime hours) can provide assistance to the patient when the patient wants to get out of bed at night (most often for toileting). 

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

The carrier's denial of coverage for the requested Personal Care Aide 7 days x (2) 12 hour split shifts is reversed. The medical necessity is substantiated.