Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:  Consumer directed personal assistance services 24 hours a day (split-shift), 7 days a week, a total of 168 hours a week.

The insurer denied consumer directed personal assistance services 24 hours a day (split-shift), 7 days a week, a total of 168 hours a week.  The determination is overturned.

The patient has a past medical history of dementia, epilepsy, autonomic neuropathy, dizziness, sleep apnea, spinal stenosis, radiculopathy, insomnia and urinary incontinence and had been assigned personal care aide (PCA) services at 12 hours/day, 7 days/week to total 84 hours/week.  There was a request to increase the PCA service hours.  Office notes from the patient's primary care physician stated she was very weak, seemed lost, and was having increased memory disturbances.  The patient had an assessment tool performed telephonically, which noted that the patient was moderately cognitively impaired.  The patient was assessed at total assistance for tasks of meal preparation, ordinary housework, managing finances and shopping and maximal assistance for tasks of managing medication, stairs and bathing.  The patient was assessed at extensive assistance for tasks of phone use, transportation, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility and eating.  Notes from the assessment state the patient ambulates with a walker indoors but has had difficulty with ambulation over the last two weeks.  The patient had a change in mental status with cursing, anger, hitting, throwing objects and resisting care. 
The patient saw her PCP with documentation of a lack of balance, falls from the bed and sofa, weakness, fatigue and memory concerns.  There was documentation of four falls since the last visit, increased memory disturbances, increased knee pain, and prescriptions for Excelon and Risperdal were refilled.  The patient's neurologist wrote a letter stating it was medically necessary to increase the hours for her home health attendants.  It also states due to her neurologic state, it is a threat to her safety and well-being if she is left unattended because she experiences moments of confusion and loss of self.  The patient's PCP wrote a letter stating that the patient has multiple chronic medical problems, which have been getting worse for the last couple of months, and will benefit by having someone to care for her 24 hours/day, 7 days/week.  At issue is the medical necessity of consumer directed personal assistance services 24 hours a day (split-shift), 7 days a week, a total of 168 hours a week.  

The 168 hours of personal PCA services  are medically necessary for this patient, given her need for 24 hour assistance with ADLs.  

The patient has a diagnosis of autonomic neuropathy and dizziness, which increases her risk of falls.  She also has a history of spinal stenosis and radiculopathy making movement difficult.  The patient has a diagnosis of dementia, which is a progressive illness and, per her neurologist, has progressed with each visit.  The patient has had multiple falls within her home related to transferring.  Due to her medical conditions, she has overnight needs, specifically to help with activities of daily living (ADLs).  The patient's primary care provider and neurologist recommended 24-hour PCA services.  The patient's PCA services are not solely for safety and supervision but to assist the patient with ADL tasks.  Personal care services are medically necessary, per the standard of care and under Medicaid when assistance with nutritional and environmental support functions are essential to the maintenance of the patient's health and safety in her own home.  Furthermore, medical necessity is defined as medical care and services that are necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity or threaten some significant handicap.