Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dementia.
Treatment:  Personal care aide (PCA) 7 hours per day, 5 days a week and 6 hours per day 2 days a week.

The insurer denied personal care aide (PCA) 7 hours per day, 5 days a week and 6 hours per day 2 days a week.  The determination is upheld.

This is a patient with a past medical history of dementia, depression, pancreatitis, osteoarthritis, atrial fibrillation, hypertension, hyperlipidemia, and urinary incontinence, who was admitted to the hospital, had abdominal surgery and transferred to rehabilitation. The patient underwent an assessment, which stated that due to the patient's confusion it was difficult for the patient to direct care, the patient ambulated with a walker, the patient had been hospitalized with a large hernia and abdominal abscess requiring surgery, and the patient had no informal help. The patient was assessed at total assistance with the tasks of ordinary housework, stairs, and transportation while maximum assistance with tasks of meal preparation, managing finances, and shopping. The patient was assessed at extensive assistance with tasks of managing medication, phone use, bathing, and dressing lower body, while limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and eating. With the task of bed mobility, the patient was assessed at independent.

The insurer sent an initial adverse determination denial notice denying request to approve personal care assistant (PCA) services stating the patient had a new diagnosis of dementia, as per psychiatrist's report, the patient's capacity for medical and discharge decisions was diminished, and the patient was able to state preferences but would have difficulty in directing personal care workers, the patient could not be left alone safely, the patient's son lived out of state and was not able to participate in the patient's care in such a capacity as required to maintain the patient in the community, and informal support and a backup caregiver could provide medication administration which is out of the scope of a personal care aide, and the patient's condition requires constant supervision for compliance with plan of care which is not in the scope of an aide for the manage long-term care program.

The insurer sent a final adverse determination denial notice denying the request to approve PCA services, stating the patient currently resided at a nursing home following a hospitalization, the patient was alert with moderate impaired decision-making and was unable to direct her care; it had been reported that the current level of care and the recommendation for long-term placement was discussed with the patient's son, and the patient lived alone, and it had been determined that she was unable to safely manage herself in the community, and it would be unsafe to discharge the patient home without a formal backup caregiver. The patient and her family appealed the denial decision. At issue is the medical necessity of a personal care aide (PCA) 7 hours per day, 5 days a week and 6 hours per day 2 days a week. 

The requested services are not medically necessary. There is documentation from the insurer that the patient has no informal support and is unable to direct care due to dementia and therefore is unable to safely manage herself in the community even with the requested PCA services 7 hours/day, 5 days/week and 6 hours/day, 2 days/week. There is documentation that the patient does not have a backup care giver, which would be necessary to direct and supervise the patient's care, and in the event that an aide is not present a backup caregiver could assist the patient with activities of daily living. There is no documentation from the patient or her family of other arrangements to provide informal support or backup care.

There is no documentation from the patient's rehabilitation facility regarding their assessment of the patient's cognitive status nor recommendations for safe discharge into the community. There is no documentation from the patient's medical provider stating the patient would be safe to remain in the community with no informal support and PCA services 7 hours a day, 5 days/week and 6 hours/day, 2 days/week. 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 7 hours/day, 5 days/week, and 6 hours/day, 2 days/week are not medically necessary for this patient.