Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: personal care aide (PCA) level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.
The insurer denied personal care aide (PCA) level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.
The determination is upheld.

This is a female patient with a past medical history of dementia, rheumatoid arthritis, systolic and diastolic congestive heart failure, macular degeneration, osteoporosis, hypertension, urinary incontinence, and bowel incontinence who had been assigned personal care assistant (PCA) services 7.5 hours/day, 6 days/week to total 45 hours/week based on assessment performed assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, and shopping while maximum assistance with tasks of managing finances, stairs, transportation, equipment management, bathing, and dressing lower body. With tasks of managing medication, personal hygiene, dressing lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of eating. The patient was assessed at supervision with the task of phone use. Notes from the assessment stated the patient had a decline in ADL (activities of daily living) status and a decline in overall self-sufficiency in the last 90 days. The patient had a fall with injuries including nasal fracture when she fell in the bathroom.

There was a request to increase PCA services and the patient underwent another assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, phone use, stairs, shopping, transportation, bathing, and locomotion while maximum assistance with tasks of managing medication, personal hygiene, dressing upper/lower body, walking, transfer toilet, toilet use, and bed mobility. The patient was assessed at limited assistance with task of eating. Notes from the assessment stated the patient was moderately cognitively impaired and had a decline in activities of daily living (ADLs) status and a deterioration of overall self-sufficiency in the last 90 days.

The patient's medical provider sent a letter stating the patient's medical diagnoses and due to the patient's dementia and cognitive decline and functional decline and physical disabilities the patient was ADL dependent and needed assistance for activities of daily life. The letter also stated due to the patient's advancing age and progressive functional decline, the patient needed extended hours of home health aide for assistance. The patient's niece also provided a letter stating the patient's previous informal helper was no longer available and the patient needed extra help from Monday through Saturday and on Sundays.

The insurer sent initial adverse determination denial notice partially denying the request to increase PCA services approving 8 hours/day stating the patient's children were supportive and involved in her care, recommended a referral to neurology, recommended a referral to physical and occupational therapy, and recommended consideration for skilled nursing facility placement. The insurer sent a final adverse determination denial notice continuing to partially deny the request to increase PCA services stating the patient had adaptive equipment and medical supplies in the home, and additional hours were not provided when tasks were not being performed. The patient and her family appealed the denial decision stating the patient was alone at night and at the patient's last doctor visit she was diagnosed with Alzheimer's. At issue is the medical necessity of personal care aide (PCA) level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The services were not medically necessary.

Although the patient has an increase in assistance needs when comparing the assessments, there is no documentation from the patient's medical provider or documentation from the assessments that the patient requires 12 x 12, split shift, PCA services. There is no documentation that the patient requires turning and repositioning every 2 hours. There is no documentation of overnight care needs that would not allow a PCA 5 hours of uninterrupted sleep. There are no overnight care logs documenting these overnight care needs either.

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 x 12 hours/day, split shift, 7 days/week, to total 168 hours/week are not medically necessary for this patient.