Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal care aide (PCA) level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split-shift)- a total of 168 hours per week
The insurer denied personal care aide (PCA) level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split-shift)- a total of 168 hours per week.
The determination is overturned.

This is a male patient with a medical history notable for dementia. The patient is currently approved for 5 hours per day, 6 days per week (30 hours per week) of personal care services. The patient and his care team requested an increase to 24 hours (2-12 hour split-shift) per day, 7 days per week (168 hours per week), and this request was denied by the health plan.

A letter of support for this appeal was provided by the patient's physician. The letter states that the patient has bowel and bladder incontinence. He now has gait difficulty and weakness, and requires assistance throughout the day and night with cleaning himself as well as changing clothes and linens following episodes of incontinence. He "lacks the cognitive and physical abilities to complete these tasks." He has unscheduled needs due to frequent urinary and bowel urgency and makes frequent trips to the bathroom. The physician notes that the patient's condition has deteriorated rapidly. He now requires assistance for ambulation. He has a history of falling due to attempts to ambulate alone. He has a history of being left on the floor in soiled clothing while waiting for his personal care aide (PCA) to arrive. He lives with his wife who also has severe dementia. He has sundowning causing him to have personal care needs throughout the night, and a live-in aide would not be expected to get 5 hours of uninterrupted sleep. For all of these reasons, the physician states that it is medically necessary that he receive continuous (24 hour split-shift) personal care services.
A Uniform Assessment System (UAS) was completed. This assessment was done with the patient and his wife present. According to the UAS, the patient's cognition was minimally impaired. He was alert and oriented times three with recall of 3/3 at 5 minutes. They reported that he gets confused often and has a newer diagnosis of dementia. From a functional standpoint, he requires total dependence for housework. He requires maximal assistance for meal preparation, managing finances, managing medications, and shopping. For his activities of daily living (ADLs), he requires extensive assistance for bathing, dressing lower body, and toilet use. He requires limited assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and bed mobility. The notes state that he requires only light touch transfer assistance for toilet transfers. He is frequently incontinent of urine and stool and uses pull-ups for incontinence care. Compared with a prior Uniform Assessment System (UAS), he showed a functional decline across most activities of daily living. At issue is the medical necessity of personal care aide (PCA) level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split-shift)- a total of 168 hour.

The requested health service of personal care aide (PCA) level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split-shift)- a total of 168 hours per week is medically necessary for this patient.

There is a fairly large discrepancy between the description of the patient's functional status in the UAS and in the letter from the physician. This may be due to the fact that the physician letter was written nearly 4 months after the UAS was completed. Another contributing factor may be that the UAS was completed with only the patient and his wife present, both of whom are noted to have dementia. They may not have been able to convey the level of functional need; the patient's wife's description of toilet transfers sounds like it not realistically within his capability given his physician's testimony. Therefore, it is appears that the patient's physician has reflected more accurately the patient's true level of need. The patient has incontinence of urine and stool and is not able to toilet by himself. He will have unscheduled personal care needs throughout the day and night. There have already been incidents related to not receiving the proper amount of personal care (which were described in the physician letter). Continued failure to provide for the patient's toileting needs could lead to skin breakdown and/or infection.