Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:  Personal care aide service hours 7 days per week, 2 12-hours split shift.

The insurer denied personal care aide service hours 7 days per week, 2 12-hours split shift.  The denial is overturned.

This is a patient with chronic medical problems including dementia, vertigo and osteoarthritis.  The patient lives alone in a 1-bedroom apartment.  The insurer reduced the patients care to personal care aide (PCA) (live-in) services, and the request is to continue PCA 7 days per week, 2 12-hour shifts.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times."  The patient's cognitive deficits are also noted as "severe" in the associated Assessor Comments section of the report.   The patient is reportedly totally dependent for performing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, personal hygiene, upper body dressing and toilet transfer/use. The patient is totally dependent for lower body dressing and locomotion (bedbound and non-ambulatory).  Extensive assistance is needed for bed mobility and eating.  The patient is frequently incontinent of bladder and occasionally incontinent of bowel.     

The patient's functional ability has declined with compared to the previous UAS report.  The letter from the patient's treating physician describing the patient's medical history and need for personal care aide was reviewed.  The photographs demonstrating the patient's lower extremity skin deterioration were also reviewed.  The patient's clinical condition and functional deficits are at a level and unpredictable as to require PCA services 7 days per week, 24 hours per day (split shift).  The patient requires routine repositioning in bed at least every 2 hours, given the patient's risk of pressure ulcers and joint contractures.  The patient's care should not be reduced to 7 days per week, live-in.  The patient's cognitive and functional ability are not improving; they are declining.  Based on the clinical records, a live-in PCA is also unlikely capable of consistently obtaining approximately 5 hours of uninterrupted sleep over the course of a 24-hour shift.  It is also agreed that attention to the patient's functional needs is more appropriately provided and maintained by the previously approved PCA 7 days per week, 2 12-hour shifts. 

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based.  

From a physical medicine and rehabilitation perspective, PCA 7 days per week, 2 12-hour shifts remain medically necessary.  

Based on the above, the insurer's denial must be reversed. 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 service hours from 7 days per week, 2 12-hours split shift is substantiated.