Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Assistance services, 24 Hours per day 7 days per week Split Shift
The health plan denied the requested Personal Care Assistance services, 24 Hours per day 7 days per week Split Shift as not medically necessary.
The health plan's determination is overturned.

The patient is a female with a past medical history of dementia, osteoporosis, coronary artery disease, cerebral vascular disease, hypertension, urinary incontinence, chronic kidney disease, edema, osteoarthritis, and diabetes mellitus type 2 who had been assigned personal care assistance (PCA) services 70 hours/week. There was a request to increase PCA services and the patient underwent an in-person assessment assessing the patient at total assistance with tasks of ordinary housework, managing finances, and shopping while maximum assistance with tasks of meal preparation, managing medication, stairs, transportation, and dressing lower body. The patient's primary care physician provided a letter requesting personal care services for the patient to meet all of the patient's personal care needs and it was medically necessary for the patient to receive 24-hour split shift personal care services a week. The provider also noted the patient was incontinent of bladder and bowel and the patient required assistance with changing her diapers throughout the day and night and needed assistance going to the bathroom at night because she has no bed mobility and falls when she tries to go to the bathroom alone. In addition, the provider noted the patient required assistance with ambulation/locomotion and transferring from one place to another and required a walker for unsteady gait and was homebound and cannot travel without difficulty. The provider also noted the patient required cueing and prompting to perform all activities of daily living (ADL) and the patient often forgot to use her rollator walker and the patient had limited informal support as the patient's daughter had her only work and family obligations. Overnight care logs noted the patient required assistance with personal care/ADLs at least every 4 hours.

The health plan's determination is overturned, in whole.

There is documentation by the patient's medical provider of medical necessity of increased PCA services specifically with assistance with transfer toilet, toilet use, and incontinence cares. The patient's cognitive decline causes her to forget to use assistive devices that may prevent falls however the patient requires at least limited assistance with tasks of walking, locomotion, transfer toilet, and toilet use. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient does not have informal help outside of the hours of currently assigned PCA services. 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 (IADL). 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, 7 days/week, split shift 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.