Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - for a total of 84 hours per week 
The insurer denied Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - for a total of 84 hours per week.
The determination is overturned.

The patient is a male with a past medical history of Alzheimer's disease, hypertension, hyperlipidemia, coronary artery disease, osteoarthritis, benign prostatic hyperplasia (BPH), obesity, congestive heart failure, diabetes mellitus type 2, thyroid nodules, low back pain, automatic implantable cardioverter defibrillator (AICD) status, diabetic neuropathy, and urinary and bowel incontinence who had been assigned personal care assistant (PCA) services 6 hours/day, 7 days/week based on an assessment. A tasking tool estimated 35 hours/week of services.
There was a request to increase PCA services and the patient underwent another assessment. A tasking tool estimated 42 hours/week.
The insurer provided a final adverse determination denial notice continuing to deny request to increase PCA services stating they had reviewed the 2 recent universal assessments as well as a letter of medical necessity from the patient's medical provider and noted the patient lived with a friend and had a daughter and friend who were supportive and involved in the patient's care. The denial also stated the patient had time allotted for housework, laundry, and meal preparation and the patient had a cane, shower chair, grab bar, walker, and incontinence supplies in the home to help manage the patient's needs. At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - for a total of 84 hours per week. 
The services are medically necessary.
There is documentation from the patient's medical provider of medical necessity of increased PCA services. The plan's most recent assessment documented at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use. The patient, therefore, 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. The patient would need PCA assistance outside of the time that he has informal support. The tasking tool underestimated the patient's care needs.
The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (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 12 hours/day, 7 days/week, to total 84 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 his own home.