Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal care aide (PCA) level 2: 8 hours per day, 5 days per week, for a total of 40 hours per week. 

The insurer denied personal care aide (PCA) level 2: 8 hours per day, 5 days per week, for a total of 40 hours per week. 
The determination is overturned. 

The patient has a past medical history of dementia, diabetes mellitus type 2 with neuropathy, uterine cancer, urinary incontinence, transient ischemic attack (TIA), open angle glaucoma, chronic pain related to right knee arthritis, hypertension, and coronary artery disease. The patient's primary care physician (or provider) (PCP) provided a letter stating the patient had a noted memory decline with difficulty with word recall, had left her stove on, burned coffee, and required assistance with meal preparation and nutritional support, needed help to complete activities of daily living (ADLs) due to cognitive impairment, neuropathy and gait dysfunction. The PCP recommended personal care assistant (PCA) services 8 hours/day, 7 days/week to ensure that her daily care was addressed. The letter also stated this level of care was medically necessary. 

The patient underwent a telephonic assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, and shopping while extensive assistance with tasks of stairs, bathing, walking, locomotion, and transfer toilet. The patient was assessed at limited assistance with tasks of transportation, personal hygiene, and dressing lower body while supervision with tasks of dressing upper body, and toilet use. With the task of eating, the patient was assessed at set up only and independent with the task of phone use. The patient was assigned PCA services 5 hours/day, 5 days/week, to total 25 hours/week. 

The patient was admitted to the hospital with chest pain. She was discharged the following day. The patient had a follow-up appointment with her PCP and they provided a letter stating patient's Alzheimer's disease had rendered her in need of support and assistance with all tasks. The letter stated it was medically necessary for the patient to receive services 8 hours/day, 7 days/week. 

The patient's neurologist provided a letter stating the patient had a diagnosis of dementia and was unable to be left alone due to burning coffee on the stove and getting lost when walking around outside. The letter stated current Home Health Aid (HHA) hours were insufficient and that she needed more supervision for a longer period of time during the day. The letter stated the provider recommended HHA services 12 hours/day, 7 days/week. 

The patient was admitted to the intensive care unit (ICU) following an episode of anaphylaxis. The patient was subsequently discharged within 48 hours. The patient underwent a telephonic assessment tool assessing the patient at total assistance with the task of ordinary housework while maximum assistance with tasks of preparation, managing finances, managing medication, and shopping. With the tasks of phone use, stairs, transportation, bathing, dressing upper/lower body, walking, locomotion, transfer toilet, and bed mobility the patient was assessed at extensive assistance while supervision with tasks of personal hygiene and toilet use. The patient was assessed at independent with eating. The assessment noted the patient lived alone, activities of daily living (ADL) status had declined and overall self-sufficiency had deteriorated. 

The insurer sent initial adverse determination denial notice denying request to increase PCA services stating the request was not medically necessary. The insurer sent a final adverse determination denial notice stating the patient needed additional services due to feeling memory and forgetfulness and granting additional hours were not provided when tasks were not being performed or for safety monitoring and supervision. The patient's daughter appealed the denial decision stating the patient was medically compromised due to her multiple medical problems, her diagnosis of dementia, uncontrolled diabetes with neuropathy, gait difficulty and high risk for falls, requesting PCA services 8 hour/day, 7 days a week. The patient's PCP appealed the denial decision. 

At issue is the medical necessity of personal care aide (PCA) level 2: 8 hours per day, 5 days per week, for a total of 40 hours per week

The services are medically necessary. There is a documented decline in the patient's assistance needs with tasks of ordinary housework, phone use, transportation, dressing upper body/lower body, and bed mobility when comparing the assessment tools. There is documentation that the patient had improvement in assistance needs with supervision and eating when comparing assessment tools despite documented decline with all ADLs by her neurologist and PCP. There is documentation that the patient had a decline in ADL status and deterioration in overall self-sufficiency in the tasking tool. The requested increase in PCA services is not solely for safety and supervision, but to assist the patient with safe completion of ADLs/instrumental activities of daily livings (IADLs). ADL and IADL 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 8 hours/day, 5 days/week, to total 40 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 her own home.