Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypertension, osteoarthritis. 
Treatment: Personal care aide (PCA) services for 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) a total of 168 hours per week. 

The insurer denied coverage for increase personal care aide (PCA) services for 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) a total of 168 hours per week. 

The denial is overturned. 
 
This is an elderly patient who has significant functional impairment associated with several medical conditions and she needs assistance with all daily activities. The Uniform Assessment System (UAS) reported the patient lives with her daughter and son-in-law, and both provide some informal help. However, the son-in-law submitted a letter stating that the patient's daughter resides in another state and is unable to provide assistance; the son-in-law lives in New York (NY) but he indicated that he cannot help the patient with personal care (e.g., bathing, dressing, toileting) because he is male. 

The records indicate the patient has dementia. The UAS includes some description of the patient's cognition including decision making for daily tasks as moderately impaired - decisions are consistently poor or unsafe, cues/supervision are needed at all times. The patient was oriented x (times) 2; she has a short term and procedural memory problem (reported as very forgetful); easily distracted; confused about time (day/night; season). The patient cannot be left alone. 

The UAS also reports a history of rheumatoid arthritis, specifically identifying right hand deformity (the patient needs weight-bearing support of the hand to assist with eating). The UAS reports the patient has severe pain in the knees, hands, and right shoulder. Shoulder pain and decreased ROM (range of motion) affects many activities including dressing, bathing, personal hygiene, toileting, and household tasks requiring reaching, lifting, and carrying. 

The patient had a magnetic resonance imaging (MRI) of the lumbar (L) spine; some of the findings include: L5 compression fracture; multilevel degenerative disc disease; severe stenosis was noted at the level of L3/L4 and L4/L5 with some nerve compression. 

Regarding toileting, the UAS indicates the patient needs maximal assistance for toilet transfer and toilet use; and also reported frequent urinary incontinence. The patient is high risk for pressure ulcers. 

The patient's mobility at the time of the UAS was reported as maximal assistance needed for walking and transfers; and the farthest distance walked without sitting was less than 15 feet. It was reported that the aide had to hold the patient around her waist while the patient leans on the walker. 

Another concern is pain management. The patient has chronic pain in her back, knees, and shoulders which may be aggravated from lying in bed in one position. A caregiver needs to be present and available to assist the patient when pain relief is needed. 

Considering the patient's medical history and functional status, it is medically necessary for the patient to have assistance for all instrumental activities of daily living (IADLs) and activities of daily living (ADLs) 24 hours per day, including: household tasks; meal preparation (all meals); medications; routine ADLs (bathing, personal hygiene, dressing, eating); plus ADLs that occur at unscheduled and/or recurring times of the day and night including toileting, incontinence care, bed mobility/repositioning, and out-of-bed mobility (if this still occurs). 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for increase personal care aide (PCA) services for 12 hours per day, 7 days per week (split shift) a total of 168 hours per week is substantiated.