Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia, Osteoarthritis.
Treatment:  Personal Care Aide (PCA) services, Live-in per diem, 24 hours per day, 7 days per week.

The insurer denied the for Personal Care Aide (PCA) services, Live-in per diem, 24 hours per day, 7 days per week.  The denial was overturned.
 
This is a male patient with a history of dementia, hypertension, anxiety, depression, dementia, osteoarthritis, urinary incontinence, tremor, constipation, and vitamin deficiency.  It was reported that the patient has increasing functional impairment and needs substantial assistance with daily activities.  The patient lives alone.  He receives PCA services 70 hours per week/10 hours per day. 

The Patient has poor balance and generalized weakness that has gotten progressively worse over the past year.  Patient improved for a few weeks after Physical Therapy (PT) but then got worse over the past couple of months.  The patient reported pain in right knee, stiffness in both knees (knee buckle when walking); decreased strength, decreased balance; decreased tolerance with standing, walking, and transfers.  The patient requires home health aide (HHA) for transfers, ambulation, and bed mobility.

The patient has a diagnosis of dementia.  He has significant memory impairment (short term and procedural) and has impaired decision making for daily tasks.  The patient's daughter reports confusion at times.  Decline in ability to perform daily activities is an expected consequence of dementia.  IADLs are usually affected before ADLs, as IADLs require a higher level of cognitive function.  The patient's cognitive deficits most likely have an adverse effect on his ability to perform IADLs (e.g. maximal assistance is needed for medications, finances), but the effect on ADLs is uncertain. 

The UAS indicates the patient has episodes of incontinence.  The frequency is not known, but if the patient is alone and cannot get up to use the commode, incontinence may occur more often.  If this occurs, the patient may remain in a wet soiled pull-up for extended periods of time at night, increasing the risk of incontinence associated skin damage (e.g. dermatitis, fungal infection, increased risk of pressure ulcers). 

Another issue that may be a potential problem is the patient's ability to move and reposition himself in bed.  The UAS indicated the patient needs extensive assistance with bed mobility.  With the patient in bed for extended hours each night, he is at risk for pressure ulcers if he does not have adequate pressure relief.  The PT note indicated patient needs HHA for bed mobility.  This may be another task needing assistance from an aide during the night.

The patient is at high risk for falls.  The physician's letter indicated the patient had frequent falls over the previous few months.  The PT notes indicate patient has poor balance and generalized weakness, which has gotten progressively worse over the past year.  He improved earlier in the year with PT but then became worse in recent months.  Patient has knee pain and stiffness with buckling during ambulation, decreased strength, and decreased tolerance with standing, walking, and transfers.  It was noted patient needs HHA for transfers, ambulation and bed mobility.  Patient has increased kyphosis (which is a risk factor for falls in older people).  The patient's score on the Berg Balance Scale was 8/56.  A score less than 45/56 indicates person is at risk for falls.  
Personal Care Aide Level 2: live-in per diem, 24 hours per day, 7 days per week is 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 Personal Care Aide (PCA) services, Live-in per diem, 24 hours per day, 7 days per week is substantiated.  The insurer's denial is overturned.