Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Personal Care Aide (PCA) SERVICES: Live-in per diem-24 hours per day-7 days per week.
The insurer denied the Personal Care Aide (PCA) SERVICES: Live-in per diem-24 hours per day-7 days per week. 
The denial was overturned.

This is a male patient with a history of anxiety, atherosclerotic heart disease of native coronary artery without angina pectoris, diabetes mellitus with unspecified complications, dysphagia, benign prostatic hyperplasia, and essential hypertension, dementia.  The patient is alert and oriented times one, with speech impairment, but able to report name through writing, and unable to write down date or location.  The patient lives in a private home with spouse. The patient's chief complaint included polyosteoarthritis, chronic pain syndrome, coronary artery disease, and anorexia.  It was reported that the patient was able to move freely in his home and could leave to visit others.  Yet it is also noted that he is unsafe alone and cannot be without help; availability of a community member for emergencies is noted. He needs maximal assistance for all activities of daily living (ADLs) and is totally dependent for meals and housework, transfers, ambulation, taking medication. His spouse passed away in early 2020. 

Patient's designee is appealing the decision.  She explained that due to the patient's advanced age and comorbid conditions the patient was followed by provider, which offered home visits, assessments, and other treatment options for homebound patients.  The letter also noted that there was consistent documentation of the patient's progressive physical decline due to advanced age and comorbid deteriorating conditions.  Urinary incontinence and the need for multiple night-time toileting sessions are highlighted.  In sum, the letter argued that the increase in personal care services was medically necessary according to generally accepted standard of care for personal care services and for geriatric and urologic medicine. 

The patient is noted to be demented and poorly communicative.  His status has changed since assessments in late 2019.  He now needs maximal assistance with all activities of daily living (ADLs) and his wife has passed away recently, leaving him alone 12 hours/day.  He has incontinence and needs the bathroom three times/night.  He needs maximal assistance with transferring out of bed and toileting and needs assistance with ambulation; he cannot do these alone.  Due to physical and cognitive impairments and need for assistance he is at high risk for falls.  His ability to contact emergency services or his daughter, who does not live with him, or get to safety if there is an emergency, have not been demonstrated.  He has hearing, visual and cognitive limitations.  He has needs that span a 24-hour period that he cannot fulfill safely on his own.  He is a suitable candidate for 24-hour PCA services. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for Personal Care Aide (PCA) SERVICES: Live-in per diem-24 hours per day-7 days per week is overturned. The medical necessity is substantiated.