Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Personal care assistance services 24 hours per day 7 days per week split-shift (Monday through Sunday) a total of 168 hours per week.
The insurer denied personal care assistance services 24 hours per day 7 days per week split-shift (Monday through Sunday) a total of 168 hours per week.
The determination is overturned.


The patient has a past medical history of chronic obstructive pulmonary disease (COPD), dementia, coronary artery disease, depression, bowel incontinence, and bladder incontinence who had been assigned personal care assistant (PCA) services 12 hours/day, 7 days/week, to total 84 hours/week. There are previous primary care physician (or provider) (PCP) notes with documentation for the requested 24 hour/day of home health aide services. The patient underwent an assessment tool on  assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, transportation, and equipment management while maximum assistance with tasks of managing medication, phone use, bathing, personal hygiene, and dressing upper/lower body. With the tasks of stairs, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of bed mobility and eating.
The insurer denied a request to increase PCA services. The insurer sent an appeal decision stating the decision made was upheld and stated the patient's son and daughter-in-law were living with the patient but moved out of state and could no longer assist with the patient's care. The decision noted safety supervision was not included and covered as part of the total authorized personal care service hours. There was another request to increase PCA services and the patient underwent assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, and transportation while maximum assistance with tasks of managing medication, bathing, and bed mobility. The patient was assessed at extensive assistance with tasks of equipment management, personal hygiene, and dressing upper body but tasks of walking, locomotion, transfer toilet, and toilet use were noted not to occur during the assessment and no estimation of care assistance was documented. Notes from the assessment stated the patient had moderately impaired cognition, was bedbound since the last two months, and required a Hoyer lift for transfers.
The insurer sent a coverage determination notice denying request to increase PCA services noting the insurer would continue to approve 12 hours/day, 7 days/week, to total 84 hours/week. Overnight logs were provided and noted overnight care needs 5 to 8 times per night including turning and repositioning to alleviate pain, toilet and incontinence cares, and assistance with drinking. The patient/patient's family appealed the denial decision. The insurer sent an appeal decision notice upholding the decision not to approve an increase in PCA services from the current services 12 hours/day, 7 days/week. The patient's PCP provided a letter stating the patient's condition had deteriorated. The provider recommended an increase in PCA services to 24 hours/day, split shift to ensure the patient had adequate assistance as she was completely bed bound and must be turned every two hours to avoid developing bed sores. The PCP's letter also noted the patient lived alone and had no formal or informal support to provide the patient with assistance to meet her personal care needs.
At issue is the medical necessity of personal care assistance services 24 hours per day 7 days per week split-shift (Monday through Sunday) a total of 168 hours per week.

Yes, the services are medically necessary. There is documentation of cognitive decline and functional decline of the patient. The insurer did not document the estimated patient assistance needs with the tasks of walking, locomotion, transfer toilet, and toilet use. Per the assessment and PCP notes, the patient was bedbound and required Hoyer transfers, therefore, the patient would have estimated total assistance needs with walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet the patient's unscheduled and unpredictable care needs. The patient requires turning and repositioning every two hours overnight and there are overnight care logs documenting these assistance needs overnight that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) / Instrumental activities of daily living (IADLs). The patient did not have informal help to meet her care needs. 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 24 hours/day, split-shift, 7 days/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 her own home.