Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease
Home Health Care/Personal Care Aide (PCA) Services: Live-In Per Diem, 1 days- 7 days per week - a Total of 7 Days per Week

The health plan denied the requested Personal Care Aide (PCA) Services: Live-In Per Diem, 1 days- 7 days per week - a Total of 7 Days per Week as not medically necessary. The health plan's determination is overturned.

This is a case review for a female with a medical history notable for Alzheimer's dementia. The patient is approved for 8 hours per day, 7 days per week (56 hours per week) of personal care aide services. The patient and her care team have requested live-in care, 7 days per week.

The patient's niece provided a letter of support for this appeal. The letter states that the patient has significantly declined following a COVID infection last year. Her dementia has worsened and she cannot perform any personal care tasks without assistance. She is not able to transfer without help, including toileting. She does not have informal family support.

The health plan denied the request for additional hours. The patient is currently residing in a nursing home and cannot be discharged until there is a safe discharge plan, and case management notes state that this includes increased personal care hours. The health plan states that the patient does not have a safe discharge plan and that is why they will not approve an increase in hours. The patient does not have someone available to assist with medication administration on discharge and a "stable caregiver to provide safety monitoring and supervision in addition to your personal care aide services upon discharge."

A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted in-person while the patient was living at a rehabilitation center following an acute hospitalization. The patient was alert and oriented to person only; her recall was 0/3 at five minutes. She does not recognize family members at times. She is unable to direct her own care. She requires maximal assistance or total dependence for all instrumental activities of daily living (IADL). For her activities of daily living (ADL), she requires total dependence for bathing, dressing lower body, walking, locomotion, and toilet transfer. She requires maximal assistance for hygiene, dressing upper body, toilet use, and bed mobility. She requires extensive assistance for eating. She is frequently incontinent of urine and stool. Compared to a prior UAS, she showed both a functional and cognitive decline.

At issue is the medical necessity for the requested health service/treatment of Personal Care Aide (PCA) Services: Live-In Per Diem, Total of 7 Days per Week.

The health plan's determination of medical necessity is overturned, in whole.

The requested health service of Personal Care Aide (PCA) Services: Live-In Per Diem, Total of 7 Days per Week is medically necessary for this patient.

The patient requires maximal assistance or total dependence for essentially all ADL and IADL. She cannot transfer, ambulate, or toilet without assistance. She is incontinent of urine and stool. Due to dementia, she is not able to direct her own care. Her personal care needs can be expected to be continuous and unscheduled in nature. She will require support for 24 hours. Therefore, a live-in personal care aide is medically necessary and appropriate.

The health plan requests an additional caregiver to provide safety monitoring and supervision. However, the increase in hours for the aide will not be for safety monitoring alone. The patient will require assistance with personal care tasks. Therefore, the request is approvable, as safety monitoring is a secondary function to supporting her personal care needs.