Appeal type: Medical necessity
Decision: Overturned

Diagnosis: bilateral amputee with schizophrenia, diabetes, hypertension, dementia, and hyperlipidemia

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - a total of 84 hours per week

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - a total of 84 hours per week

The denial is overturned

 
The patient is an adult female who is a bilateral amputee with schizophrenia, diabetes, hypertension, dementia, and hyperlipidemia. She is incontinent for bladder and bowel. She has cognitive limitations. She was hospitalized with a urinary tract infection (UTI). A clinical review was performed. Medical equipment in use includes bedside commode, glucometer, hospital bed, raised toilet seat, shower chair, shower grab bar, and wheelchair. She requires maximal assistance with dressing upper and lower body, personal hygiene. The record notes toileting care remained the same from previous assessment, therefore aide services will remain the same. The provider sent a letter requesting the patient receive 12 hours per day 7 days per week of in-home health aid. She notes the patient needs the additional hours due to physical limitations. The patient tends to wander and has injured herself. Her condition is worsening. She is unable to transfer from her wheelchair to the bed, toilet, etc.

The daughter sent a letter. She notes her mother is unable to transfer from chair to toilet or to other surfaces like she used to. She needs help with cleaning and toileting as evidenced by hospitalization with a UTI due to urinating her pull-ups frequently. She notes her mother lives alone. She noted that during the phone assessment by the nurse, it was indicated that her mother could transfer without assistance. Her mother is unable to transfer without assistance due to falling multiple times from her bed. She requires toileting assistance throughout the day. The patient's neurologist sent a letter requesting 12 hours per day of care. The patient's progressive short term memory loss, and episodes of confusion are worsening. Based on her neurological, psychiatric, and physical needs, she requires assistance over 12 hours daily. 

The review of assessments, checklists, clinicals and letters found that this patient should not be left alone and the request for 12 hours per day 7 days per week is appropriate and medically necessary. Two separate providers noted her cognitive and physical deficits. They both noted a decline in her abilities to perform activities of daily living (ADLs). The assessment did not allot any time for toileting and bathing and as indicated by the submitted records, this patient cannot do these tasks without assistance. The decision is overturned, and the patient is to receive 12 hours per day 7 days per week. 

Based on the above, the insurer's denial must be overturned. 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 (PCA) Level 2: 12 hours per day - 7 day(s) per week - a total of 84 hours per week services is substantiated.