Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease
Treatment: Personal Care Aide Services
The insurer denied the Personal Care Aide Services
The determination is overturned.

The patient has a past medical history of Alzheimer's dementia, diabetes mellitus (DM) type II, osteoarthritis, low back pain and urinary/fecal incontinence who had been assigned personal care aide (PCA) services, 12 hour/day, 7 days/week to total 84 hours per week.
The patient's neurologist wrote a letter stating patient's dementia continues to progress, requires assistance with activities of daily living (ADLs)s and is experiencing delusions and hallucinations. The letter goes on to say the patient frequently urinates and defecates and not necessarily in the commode and turns on the stove and leaves it on. This provider stated "it is medically necessary for the patient to have full time (i.e., 24 hours per day) home health aide coverage because she is a danger to herself. It is not safe for her to be left alone for any part of the day".
The patient's psychiatrist wrote a letter noting the patient has deterioration of dementia with delusions and hallucinations and disturbed sleep/wake cycle. The psychiatric provider also stated in the letter "she needs home health aide supervision for 24 hours coverage full time, in her familiar home environment (she lives alone), in order to manage her developing symptoms of disturbed sleep wake cycle, helping in her daily special need activities, and mostly from preventing her from harming herself and others".
The patient's palliative care and geriatric provider wrote a letter stating the patient is unable to engage in self care with incontinence of urine and feces with the need for assistance in bathing after these episodes. The letter also noted, the patient's daughter installed camera's in the patient's apartment and the patient was observed on video urinating and defecating in the kitchen and bathroom garbage cans as well as turning on the stove and climbing on the furniture. This provider states " current level of care is inadequate, due to the progression of dementia which has caused cognitive deterioration and her physical impairments. Provision of personal care services 24 hours 7 days per week is medically necessary.".
The patient had a uniform assessment performed over the telephone. There was a reduction in assessed assistance need for tasks of meal preparation and managing finances from total assistance to maximum assistance compare to her previous in person assessment. In addition, the assistance with tasks of bed mobility and eating improved from limited to independent and limited to supervision, respectively. The patient had an increased need of assistance in tasks of transportation from extensive to maximum compared to previous in person assessment  All other tasks were assessed at the same level as in person assessment , noting extensive assistance with tasks of phone use, stairs, bathing, personal hygiene, dressing upper/lower body and toilet use while assessed at limited assistance with tasks of walking, locomotion and transfer toilet.
There was a final adverse determination provided from the insurer denying an increase in PCA service hours to 24 hours/day, split-shift, 7 days/week to total 168 hours/week. The patient's palliative care/geriatric provider again provided a note stating the patient was incontinent of urine and feces, unable to engage in self care, that her condition was worsening and progressive and that it was medically necessary for the patient to have personal care services 24 hours 7 days per week (split-shift). At issue is the medical necessity of these services.

Yes, The patient has progression of underlying dementia with decreased ability for self care, urinating and defecating in places other than the toilet/commode, turning the oven on without turning it off, having increased delusions/hallucinations and having a worsening sleep/wake cycle.
All of these factors, as well as the patient's psychiatrist, neurologist and geriatrician noting the medical necessity of 24 hour/day, 7 days/week of PCA services support the need for such. Her geriatrician specifically notes it is medically necessary for the patient to have split-shift coverage for 24 hour PCA services. The patient is often up at night due to disturbance of sleep wake cycle and requires assistance with tasks of bathing, personal hygiene and toilet use which would occur at unpredicted times in the overnight hours. The split shift PCA is not solely for supervision and safety as the patient requires aid and queues to complete ADLs.