Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) 84 hours per week 
The insurer denied Personal Care Aide (PCA) 84 hours per week.
The determination is overturned.

The patient has a past medical history of urinary incontinence, bowel incontinence, hypertension, cerebrovascular accident (CVA) with left hemiplegia, coronary artery disease, stage 1 pressure ulcer, osteoarthritis, hyperlipidemia, hearing loss, macular degeneration, congestive heart failure, and vascular dementia. He had been assigned personal care assistant (PCA) services 45 hours/week based on a video assessment assessing the patient at total assistance with the tasks of meal preparation and ordinary housework, stairs, shopping, and transportation while maximum assistance with the task of managing medication. With the tasks of phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating the patient was assessed at extensive assistance while limited assistance with the task of managing finances. Notes from the assessment stated the patient had been in a nursing home and rehabilitation (rehab) following hospitalization with a stroke and left nondominant hemiplegia. The patient was seen by physical therapy and occupational therapy throughout the rehabilitation stay for restorative therapy. The patient desired to return to the community with a plan to request increase in PCA services.
The insurer sent an initial adverse determination denial notice stating there was a request for approval of PCA services 84 hours/week but the plan made a decision to keep PCA services at 45 hours/week. The patient underwent a video assessment assessing the patient at total assistance with the tasks of ordinary housework, meal preparation, stairs, and shopping while maximum assistance with the tasks of transportation, bathing, transfer toilet, and toilet use. With the tasks of phone use, personal hygiene, dressing upper/lower body, locomotion, and bed mobility the patient was assessed at extensive assistance while limited assistance with tasks of managing finances and managing medication. The patient was assessed as independent with the task of eating. Notes from the assessment stated the patient was non-ambulatory and used a wheelchair and had another relative as informal help.
The insurer sent a final adverse determination denial notice denying the request to increase PCA services stating safety monitoring should not be authorized in the absence of 1 or more activities of daily living (ADL) needs and a review of the nursing assessments showed no significant change in his ability to perform ADLs. The patient's primary care physician (or provider) (PCP) provided a letter requesting an urgent increase in the hours of home care for the patient due to his rapidly deteriorating mental and physical health and functional status. The PCP further stated he recommended it was very important and medically necessary for the patient to have 12 hours of home care, 7 days/week, to maintain his current health and functional capacities and prevent illness progression. The patient appealed the denial decision. The patient's healthcare advocate provided a letter stating it was incorrect that the insurance company indicated the patient was alert and oriented and could direct his care as this was incorrect with the patient having advanced age vascular dementia. The healthcare advocate also stated the patient had been hospitalized which worsened the patient's functional capacity as he had a myocardial infarction.
At issue is the medical necessity of a Personal Care Aide (PCA) 84 hours per week.
The services are medically necessary. There is documentation of cognitive and functional decline from the nursing home records as well as from the patient's PCP. The video assessment underestimated the patient's care needs with ADLs as the occupational therapy (OT) and physical therapy notes indicate a higher need of assistance with walking, locomotion, and dressing lower body. The patient requires maximum assistance with transfer toilet, toilet use, and incontinence care. The patient has 24-hour care needs and therefore a task based assessment tool should not have been utilized to determine PCA hours. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 84 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 his own home.