Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease.
Treatment: Personal Care Assistant (PCA) services - 7 days per week, 24 hours per day continuous split shift by more than one person, 168 hours per week.

The health plan denied the PCA services - 7 days per week, 24 hours per day continuous split shift by more than one person, 168 hours per week.  The health plan's determination is overturned.

The patient is a female with past medical history of dementia- Alzheimer's type, osteoporosis, chronic low back pain, hypertension, hyperlipidemia, atrial fibrillation on chronic anticoagulation, glaucoma, urinary incontinence, and fecal incontinence who had been assigned personal care assistant (PCA) services at 4 hours/day, 7 days/week, to total 28 hours/week based on the last assessment. There was a request to increase PCA services and the patient underwent telephonic assessment tool, assessing the patient at total assistance with tasks of ordinary housework, managing finances, and shopping, while maximum assistance with tasks of meal preparation, managing medication, phone use, transportation, and equipment management. The patient was assessed at extensive assistance with tasks of stairs, bathing, dressing lower body, and toilet use, while limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, bed mobility and eating. Notes from this assessment stated that the patient had recently fallen out of bed in the evening without specific injury, that there was a decline in ADL (activities of daily living) status, and had scored a 9 out of 30 on the Mini-Mental State Examination (MMSE).

At issue is the medical necessity of the requested increase in personal care assistant hours.

The health plan's determination of medical necessity is overturned, in whole.

Yes. The patient has documentation of progressive and worsening medical conditions of dementia, urinary incontinence, and fecal incontinence. The patient requires at least some assistance with all ADLs (activities of daily living) /IADLs (instrumental activities of daily living). Due to the patient's medical condition of dementia, she has an unpredictable sleep schedule with 24-hour ADL needs. The patient has unpredictable and unscheduled care needs over a continuum of time, and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. It is documented that the patient requires assistance with walking, locomotion, transfer toilet and toilet use at least 3-4 times overnight, which would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. They request to increase PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The daughter has been living with the patient and is unable to continue informal support at the current level, and the plan did not take this into account when making their decision. 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, 7days/week, to total 168 hours/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.