Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe dementia, hypertension, heart failure 
Treatment: Personal care assistant service
The insurer is denied coverage for personal care assistant service (continuous services).
The denial is reversed. 

The patient is a female with diagnoses that included dementia, depression, hypertension, hyperlipidemia, GERD, rheumatoid arthritis, and pain. She lived with her sister in a one bedroom apartment (senior housing). Previously they were receiving 12 hours a day of home care hours as a mutual case. The niece requested 24 hour split shift because the patient's condition has deteriorated. The patient and sister were admitted to the hospital at different times in the past. After hospitalization the patient's dementia is worse and she has new diagnosis of right sided heart failure. She had a stage 1 pressure ulcer on her back which was followed by home care services. When her sister was in better condition, she was able to assist the patient at night, but the sister is now unable to provide help due to the sister's decline in health. The patient needs assistance with all ADLs. She is unable to communicate her needs. She is incontinent of urine and stool and requires assistance to change her underpads day and night. The niece wants to have her aunt and mother live at home as long as possible, as they are a comfort to each other.

The patient has severe dementia, hypertension, heart failure, incontinence. She is high risk for falls due to difficulty ambulating. She needs assistance with all ADLs. It is recommended that the patient has 24 hour home health aide for around the clock care.

The patient has severe dementia; diagnosis Alzheimer's disease. She is incontinent of bladder and bowel, unable to make her needs known. She requires frequent diaper changes to prevent skin ulceration and potential infection. The patient needs 24 hour supervision and assistance with all ADLs.

The earlier UAS was provided for review. This was done a few days before the patient was hospitalized for pneumonia. Comparison of the UAS reports indicates decline in several ADLs later UAS (bathing, dressing upper/lower body, bed mobility, eating); decision making capacity declined from minimally to moderately impaired. The patient was continent (urine incontinence). The patient completed timed 4 meter walk (23 sec) and could walk > 300 ft without siting down; the patient refused timed 4 meter walk; can walk < 15 ft without sitting down. 

Based on the information provided for review, the patient is at high risk for incontinence associated complications, pressure ulcers, and falls during the night. Therefore, it is medically necessary for the patient to have a caregiver present at night to provide ADL assistance for toileting/incontinence care, bed mobility, and assistance with transfers and walking if the patient needs to get out of bed. There are no informal caregivers who can provide assistance to the patient during the sleep period for a live-in aide.

Personal Care Assistant service, 7 days x 24 hours (continuous services) per week are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the request for personal care assistant (PCA) service 7 days x 24 hours (continuous services) is substantiated. The insurer's denial is reversed.