Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intraparenchymal hemorrhage and vascular dementia.
Treatment: (PCA): 12 hours per day-7 days per week (split shift)- a total of 168 hours per week.
The insurer denied (PCA): 12 hours per day-7 days per week (split shift)- a total of 168 hours per week.

The determination is overturned.

The patient has a past medical history of hypertension, hyperlipidemia, breast cancer, cerebral hemorrhage, vascular dementia, gastroesophageal reflux disease (GERD), osteoarthritis, and bladder incontinence who had been assigned personal care aide (PCA) services 8-1/2 hours a day, 7 days/week, to total 59.5 hours/week based on a telephonic assessment tool performed assessing the patient at total assistance for meal preparation, ordinary housework, managing finances, shopping, and locomotion while maximum assistance with tasks of managing medication, phone use, stairs, transportation, bathing, personal hygiene, dressing upper body/lower body, walking, transfer toilet, toilet use, bed mobility, and eating. Notes from the assessment stated the patient used a wheelchair or scooter for locomotion, was more forgetful and disoriented, required significant weight bearing support to the upper extremities, overall self sufficiency deteriorated, required significant weight bearing support to hold utensil and eat, and required significant weight bearing support for toilet use and help with incontinence supplies.
The patient was hospitalized with altered mental status, a urinary tract infection (UTI), and abnormal electroencephalogram (EEG). The patient was referred to hospice but did not meet criteria and was sent home with services, a Hoyer lift, and hospital bed. There was a request to increase the PCA services and the patient had another telephonic assessment tool performed assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, transportation, bathing, personal hygiene, dressing lower body, walking, locomotion, and toilet use while maximum assistance with tasks of phone use, dressing upper body, bed mobility, and eating. The task of transfer to toilet did not occur.
Notes from the assessment stated the patient lived alone, had severely impaired cognitive skills, had confusion, had contractures of the hands, and debility with activities of daily living (ADL) status decline over the last 90 days. In addition, the notes stated the patient was unable to get out of bed, was unable to walk or stand, required total assistance with transfers, walking, and locomotion, had a hospital bed and Hoyer lift to assist the caregiver with transfers, required complete assistance with putting on pampers and socks, required significant weight bearing for toilet use, the caregiver performed all cleaning of the perineal area, had no strength to pull herself up in bed, was able to turn and hold on to the bedrail on some occasions to be turned side to side, and required significant help with eating.
The insurer provided an initial adverse determination denial notice partially denying the request for increased PCA services by increasing them to 9.5 hours/day, 7 days/week, to total 66.5 hours/week. The partial denial stated the request was not medically necessary and the patient's daughter directed her care, the patient had a walker, wheelchair, shower chair, shower grab bar, and bedside commode to assist her needs, the patient required safety monitoring as a standalone task, and the patient was sometimes incontinent of bowel and bladder function.
The insurer sent a final adverse determination denial notice denying the request to increase PCA services to 12 hours/day, split-shift, to total 168 hours/week. The patient's primary care physician (PCP) provided a letter stating the patient's diagnosis of intraparenchymal hemorrhage and vascular dementia. The letter further stated the patient needed assistance with toileting, bathing, showering, and medication management. Lastly, the letter stated "patient requires 24/7 assistance for reasons of medical necessity and safety".
At issue is the medical necessity of personal care aide (PCA): 12 hours per day-7 days per week (split shift)- a total of 168 hours per week.

The services are medically necessary.

The patient has documented progressive medical diagnoses of vascular dementia and osteoarthritis with hand contractures with documented worsening of functional and cognitive functioning. The patient was hospitalized with a plan for hospice care but the patient did not meet criteria. The patient requires a hospital bed and a Hoyer lift for transfers. The patient is not able to ambulate. The patient has a least maximum assistance with all ADLs/Instrumental activities of daily living (IADLs). The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not develop a plan to meet those unpredictable and unscheduled care needs. The patient requires assistance outside of the time the patient has informal support. The patient is not able to reliably turn and reposition in bed and would require frequent turning and repositioning to alleviate pain and prevent skin breakdown. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's care needs cannot be met with 9.5 hours/day and/or with adaptive equipment and/or medical supplies. The patient's care needs in the overnight hours, specifically toileting and incontinence care and turning and repositioning would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. 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 12 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary under when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.