Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-Alzheimers. 
Treatment: Home health care-PCA services. 

The health plan denied the increase in PCA services as not medically necessary. The reviewer has overturned in whole the health plan determination. 

The patient is elderly with past medical history of advanced dementia, urinary incontinence, dizziness, weakness, difficulty walking, generalized osteoarthritis, abnormality of gait, carpal tunnel in both hands, shortness of breath, edema, syncope, hypertension, implantable loop recorder, chronic kidney disease, anemia, hyperlipidemia, myelodysplastic syndrome, dyspnea, hypothyroidism, asthma and COPD(Chronic obstructive pulmonary disease) who had been assigned 5.5 hours/day, 7 days/week to total 38.5 hours of PCA(personal care assistant) services based on assessment tool performed. Prior to this assessment the patient's PCP provided a letter stating the patient has dementia which makes it unsafe for her to be alone as she does not remember to eat if someone is not there to prepare her meals and has left her oven on when trying to prepare meals. This letter stated the patient should be under 24 hour supervision for her safety and well-being. The patient's cardiologist provided a letter stating the patient was seen for multiple episodes of syncope and has an implantable loop recorder. At the initial assessment the patient was noted to be total assistance with meal preparation, ordinary housework, managing finances, shopping, and transportation while maximum assistance with tasks of managing medication. For tasks of stairs, bathing, personal hygiene, dressing upper and lower body and toilet use the patient was assessed at extensive assistance while supervision with tasks of phone use, walking, locomotion, and transfer toilet while independent with bed mobility and eating. 

This assessment noted the patient to be alert and oriented x two, that the family unplugged her stove for safety reasons, that the patient would not eat unless food was put in front of her, that the family installed cameras in the home to monitor the patient and that the family had to call patient to remind her to take her evening medication but the aide often found them still in the mediset the next morning. The patient had a fall while alone and did not know what happened and did not push her life alert button. The patient was found on the floor by her aide in a pool of urine and stool and the patient did not recall what happened and injured her left ankle that was diagnosed with fracture the following day. The patient was wearing her life alert button and did not push it. There was a request to increase PCA service hours and the patient had an assessment tool performed noting the patient forgets to turn the stove off, wakes up at night and wanders, and has smeared feces in inappropriate places. On this assessment the patient was assessed at total assistance for tasks of meal preparation, ordinary housework, managing finances, shopping, and locomotion while maximum assistance with managing medication, phone use, stairs, transportation, bathing and dressing lower body. This assessment noted patient to need extensive assistance with tasks of personal hygiene, dressing upper body, walking, transfer toilet and toilet use while supervision for tasks of bed mobility and eating. The plan did increase PCA service hours to 6.5 hours/day, 7 days/week to total 45.5 hours. The patient's neurologist provided a letter stating the patient is in need of help in the house for 24 hours for safety reasons and also for all activities of daily living with the need for help with medications, eating, toileting, dressing and showering for safety reasons. The patient had another fall and was found naked on the floor by her daughter and the patient did not know how she got there but appeared to have fallen while attempting to shower as there was a soiled diaper found. The patient's daughter provided a letter summarizing the patient's deteriorating mental capacity. The patient's advocacy group provided a letter stating the patient lives alone, forgets to eat and drink becoming dehydrated, cannot move in with family members, and is unable to change pull ups herself. The advocacy letter noted the final adverse determination letter incorrectly stated the patient's cognitive skills remained the same. This letter also stated the patient is at high risk for infection due to being left and found with soiled diaper when the aide arrives. This letter from the advocate also stated the patient's task assessment tool did not take into account the time to carry out tasks and rest periods in between. 

The requested increase in PCA services to 12 hours per day, 7 days per week for a total of 84 hours per week are medically necessary for this patient. 

The patient had a documented decline in cognitive capacity as per the assessment tools performed. The patient requires assistance with eating three meals daily as well as prompts to drink as she forgets due to her dementia. The patient was assessed as total assistance with locomotion and contact assistance with walking with needed reminders to use her walker when she is walking. The patient needs prompting to take her medication with administration times at least twice daily. The patient requires assistance with tasks of personal hygiene, toilet use, transfer toilet, walking, locomotion and eating outside of the hours the patient has PCA services. The patient no longer has an informal helper outside of the hours of her PCA. PCA services for this patient are not solely for supervision and safety (as documented by her neurologist, family, and advocacy letter). The patient has had three falls when left alone in an attempt to walk without her walker, bathe by herself and perform toileting/incontinence cares. 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.