Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) 12 hours/day, 7 days/week; 12 hours/day, 7 days per week - total of 168 hours/week 
The insurer denied PCA 12 hours/day, 7 days/week; 12 hours/day, 7 days per week - total of 168 hours/week. 
The denial is overturned.

The patient is a female with past medical history of dementia, hypothyroidism, urinary incontinence, stool incontinence, ataxia, status post right hip fracture, status post right ankle surgery, mid back pain due to compression fracture, coronary artery disease, insomnia, carotid artery plaque, bipolar depression, and osteoarthritis who had been assigned Personal Care Assistance (PCA) services 8 hours/day, 5 days/week, and 6 hours/day, 2 days/week, to total 52 hours/week based on a telephonic assessment performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, stairs, transportation, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at extensive assistance with tasks of phone use, personal hygiene, dressing upper body, bed mobility, and eating. The patient was hospitalized for urinary tract infection with subsequent transfer to rehabilitation with a request to increase PCA services following rehabilitation stay.

The subject under review is the medical necessity for PCA 12 hours/day, 7 days/week; 12 hours/day, 7 days per week - total of 168 hours/week.

The health plan's determination is overturned.

There is documentation from the patient's medical provider of worsening cognitive and functional status. There is documentation from the patient's medical provider of medical necessity of frequent changing of soiled diapers every 2 hours to prevent infection and skin breakdown. The patient requires maximum assistance with transfer toilet and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The insurer incorrectly assumed that the patient's daughter could provide informal help outside of the currently assigned PCA hours. The insurer also incorrectly assumed the patient was attending social daycare following her rehabilitation stay, which was not the case. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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). Furthermore, the patient's medical condition of dementia causes insomnia with the patient requiring assistance needs with ADLs in the overnight hours. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA 12 hours/day, 7 days/week; 12 hours/day, 7 days per week - total of 168 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.