Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional impairment, dementia. 
Treatment: Personal Care Aide (PCA) services (split shift) 24 hours per day, 7 days per week. 
The insurer denied coverage for Personal Care Aide (PCA) services (split shift) 24 hours per day, 7 days per week. 
The denial is overturned. 

This is an elderly female with extensive medical history who has significant functional impairment and needs a high level of assistance with all daily activities. The patient lives alone. The patient mostly relies on personal care aide (PCA) services for assistance with Activities of daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). She receives Personal Care Aide (PCA) live-in services, 7 days per week. The patient (via designee) requested Personal Care Aide (PCA) services 24 hours (split shift) per day, 7 days per week, which was denied. 

The most recent Uniform Assessment System (UAS) provided for review showed that functional status for Instrumental Activities of Daily Living (IADLs) indicates the patient was totally dependent for meal preparation, shopping, ordinary housework, managing finances, phone use, stairs, equipment management; she needed maximal assistance for managing medications, transportation. For Activities of Daily Living (ADLs), the patient was totally dependent for bathing, dressing lower body, toilet use, locomotion; she needed maximal assistance for personal hygiene, dressing upper body, transfer toilet, bed mobility, eating. 

The patient has dementia, reported as vascular type in Uniform Assessment System (UAS). The patient's decision-making for daily tasks is described as severely impaired (rarely or never makes decisions). She was oriented to self; with short term, procedural, and situational memory problem. She has frequent periods of confusion; easily distracted; and needs cues to perform personal care and daily activities. The patient's communication ability is limited to making concrete requests; she responds to simple, direct communication only. The letter from the nurse practitioner (NP) indicated the patient has severe mental deterioration due to dementia. 

The patient has anxiety and depression (treatment is noted in the medication list). Some behavioral symptoms were reported by the daughter and aide including crying, screaming at night, frequent visual hallucinations, calling someone who patient believes is in her room. 

The patient is totally dependent for toilet use (which includes incontinence care) and she needs maximal assistance for toilet transfer. The patient has no bladder control and frequent bowel incontinence. 

It is necessary for a caregiver to be present and awake during the day and night to assist the patient with the toilet transfer and toilet use; check the patient on a regular basis for incontinence; and provide prompt incontinence care to help prevent complications (as noted above). The daughter and aide reported patient tries to stand up from bed, but she is unable to stand unassisted; so she is at risk for falls. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Personal Care Aide (PCA) services (split shift) 24 hours per day, 7 days per week services is substantiated.