Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal care aide (PCA) level 2: live in per diem- 24 hours per day, 7 days per week. 

The insurer denied the Personal care aide (PCA) level 2: live in per diem- 24 hours per day, 7 days per week. 

The determination is overturned. 

The patient has a past medical history of Alzheimer's disease, anxiety, fecal smearing, decreased verbal communication, insomnia, hypertension, hyperlipidemia, coronary artery disease, congestive heart failure, osteoarthritis with chronic pain, osteoporosis, lumbar radiculopathy, and claudication who had been assigned personal care assistant (PCA) services 6 hours/day, 7 days/week, total 42 hours/week based on an assessment tool performed. The patient was assessed at total assistance with tasks of meal preparation and ordinary housework while maximum assistance with task of shopping. The patient was assessed at extensive assistance with tasks of stairs, transportation, bathing, and dressing lower body while limited assistance with tasks of managing finances, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility. With the task of phone use the patient was assessed at set up only and with the task of eating, the patient was assessed as independent. 
The patient's psychiatrist provided a letter stating the patient suffered from advanced stage of dementia with progressive loss of level of functioning due to her dementia and multiple medical problems. In addition, the letter stated the patient was unable to organize her daily activities, unable to take care of her daily routines without assistance, had frequent falls with difficulty ambulating on her own, and was in need of increase in PCA service hours. 

The patient saw her cardiologist with a change in medication and recommendation to fluid restrict to 1000 milliliters (ml) per day. The patient underwent a telephonic assessment tool assessing the patient at the same level of assistance with tasks as compared to the previous assessment. Notes from the assessment stated the patient lived alone and the family helped her with medication administration then hides the medication as patient has taken incorrectly. The insurer sent an initial adverse determination denial notice denying the request to increase PCA services stating the request was not medically necessary and recommended a social worker for a safe return bracelet, discussed long term care placement with the patient's daughter, and educated the daughter on safety precautions related to wandering. There was a request to increase PCA services to 12 hours/day, 7 days/week, to total 84 hours/week and the insurer sent another initial adverse determination denial notice denying the request to increase PCA hours stating the request was not medically necessary, reiterating the assessment tool assistance needs from the assessment and that PCA services 6 hours/day, 7 days/week, to total 42 hours/week were sufficient to meet the patient's needs. The patient fell and had a closed fracture of the right wrist with hospitalization and treatment for pneumonia. The discharge summary/paperwork stated the patient had decline in functional status as she could not coordinate due to mental status and required assist with rolling walker for ambulation and commode. In addition, the discharge paperwork stated the patient had to have 24/7 coverage of a home health aide, otherwise the patient would be in danger staying home herself. 

The insurer sent a final adverse determination denial notice stating partial denial with approval of PCA services 12 hours/day, 7 days/week, to total 84 hours/week. The denial stated the request for increased PCA services was not medically necessary and the patient did not meet criteria. The denial stated the patient underwent a telephonic assessment tool assessing the patient at total assistance with tasks of meal preparation and ordinary housework while maximum assistance with tasks of managing medication, bathing, dressing lower body, walking, locomotion, and transfer toilet. The patient was assessed at extensive assistance with tasks of personal hygiene, dressing upper body, toilet use, and bed mobility. In addition, the denial letter stated the patient had a Personal Emergency Response System (PERS), shower chair, shower grab bar, and incontinence supplies to assist patient with her needs. The denial letter stated additional hours are not provided when tasks are not being performed and for safety monitoring and supervision. 
The patient's primary care physician (or provider) (PCP) provided a letter requesting an urgent increase in hours of home care for the patient due to her rapidly deteriorating mental state, physical health, and functional status. The letter further stated the patient is unable to independently carryout normal activities of daily living and is completely dependent on her home health aide to do so. In addition, the PCP letter stated the patient can no longer perform activities of daily living, such as, cooking, cleaning, bathing, dressing, grocery shopping, lifting objects, reaching overhead, maintaining her household, preparing and administering medication and meals three times a day, self care, household chores, transportation, and multiple daytime and nighttime changes of soiled diapers and linens to prevent skin rash and irritation, and human assistance and support in her mobility, especially during the nighttime, to serve as fall prevention. At issue is the medical necessity of personal care aide (PCA) level 2: live in per diem- 24 hours per day, 7 days per week. 

The services are medically necessary. The patient has documented progressive medical conditions of dementia, osteoarthritis and had fracture of the right wrist. The patient requires at least some assistance with all activities of daily living (ADLs)/ Instrumental activities of daily living (IADLs). The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met solely with medical equipment and supplies. The requested 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 PCP documented medical necessity of requested increase in PCA hours. 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, live-in, 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.