Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA): 8 hours per day - 7 days per week - for a total of 56 hours per week 
The insurer denied: Personal Care Aide (PCA): 8 hours per day - 7 days per week - for a total of 56 hours per week 
The denial is: Overturned

The patient is a female with medical history notable for dementia, urinary incontinence, and gait disturbance. The patient is currently receiving 7 hours per day, 6 days per week of personal care services (42 hours per week). The patient's care team requested an increase to 8 hours per day, 7 days per week (56 hours per week). This request was denied by the insurance company and is the subject under review.

A Uniform Assessment System (UAS) was completed and was available for review. The assessment describes the patient's cognition as "minimally impaired." She is alert and oriented times two (reporting the current year is 1946), with recall 0/3 after five minutes and forgets how to boil water or the name of her daughter. She will lock herself into the bathroom and forget how to come out. From a functional standpoint, she requires total dependence for meal preparation, housework, and managing finances. She requires maximal assistance for managing medications. For her activities of daily living (ADLs), she requires extensive assistance for nearly all, including bathing, hygiene, dressing upper/lower body, walking, locomotion, toilet transfer, and toilet use. She requires limited assistance for bed mobility and is independent with eating. She is frequently incontinent of urine (daily) and occasionally incontinent of stool. She wears diapers for incontinence. An associated tasking tool recommended 38.5 hours per week for level 2 personal care services, and also recommended 7 days per week. Compared with a prior assessment, the patient showed a significant decline in cognition and functioning in ADL's and Instrumental activities of daily living (IADLs). She previously was independent with hygiene and only required limited assistance for walking, locomotion, toilet transfer, and toilet use. The tasking tool recommended 27 hours over 6 days a week at that time for personal care services.

The health plan's determination is overturned.

The requested health service/treatment of Personal Care Aide (PCA): 8 hours per day - 7 days per week - for a total of 56 hours per week is medically necessary for this patient.
When comparing the UAS from last year to this year, it is clear that the patient has had significant decline in both cognition and ADL/IADL function. She is now less capable of making her needs known, requires greater assistance with activities, and has developed incontinence. It is completely reasonable to modestly increase her hours given her worsening condition. Furthermore, although the tasking tool recommends 38.5 hours per week, it does recommend 7 days per week of personal care. Tasking tools can be useful as a guideline but can underestimate the true need of a patient that has a combination of dementia and incontinence. Prompt attention to toileting needs is essential to prevent skin breakdown and/or infection.
The health plan denied the request in part due to personal care hours not being appropriate for safety monitoring and supervision alone. However, the details of this case show that there is a medical need for personal care services to be performed and thus the aide would not be functioning for safety monitoring alone.