Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia 
Treatment: PCA Level ll; 70 hours per week, 10 hours per day, 7 days per week 

The insurer denied the PCA Level ll; 70 hours per week, 10 hours per day, 7 days per week. The denial was reversed. 

This is a female patient with a history of dementia with behavioral disturbance, hypertension, CKD stage 4, hyperlipidemia, hypothyroidism, peripheral autonomic neuropathy, osteoarthritis, artificial hip joint, spinal stenosis, dizziness, glaucoma, and hearing loss. The patient lives in an apartment in an assisted living facility. Due to the patient's declining medical conditions she requires an increase in the personal care services (PCA). It was reported that she is receiving services 5 hours per day, 7 days per week. The patient has short term memory loss with functional impairment. There has been a decline in her ability to perform independent activities of daily living (IADLs) and requires assistance with all activities including walking, transfers, toileting/incontinence care, oral intake, bed mobility. She has frequent episodes of incontinences creating issues with self-toileting. There has been a reported decline in her oral nutritional intake causing a recent weight loss. A request was made for an increase in her PCA to PCA Level ll; 70 hours per week, 10 hours per day, 7 days per week. 

The patient has dementia. There are no neurologic/cognition evaluations available for review to fully describe the patient's cognitive abilities and severity of disease, it appears the patient has significant cognitive impairment. The patient's decision making capacity is described as severely impaired. The patient has short term, procedural and situational memory loss; does not remember daughter's name; needs prompting/cues for most tasks. Dementia is associated with functional impairment. 

The patient has CKD stage 4. There are no details available, but at this advanced stage of CKD, various symptoms occur and can affect daily function, including: fatigue, weakness, loss of appetite, neuropathy, and cognitive dysfunction. The patient's advanced renal disease may be contributing to her recent decline, including: fatigue, excessive sleeping, decreased appetite, decreased mobility, increasing confusion. 

The patient has more frequent episodes of incontinence. There are various causes of urinary and fecal incontinence. In additional to causes directly associated with dysfunction of the urinary and gastrointestinal (GI) tract, functional incontinence occurs due to mobility and cognitive impairment which results in difficulty and delay in reaching a toilet in time. With dementia, people eventually lose the ability to recognize what to do and where to go when the need to use a toilet occurs. With report of recent decline in mobility and increasing cognitive impairment, these problems may be contributing to the patient's recent increase of incontinence episodes. 

The patient's oral intake is declining and she is losing weight. Weight loss and poor appetite in the elderly have many causes. In this case, the patient has dementia, which often results in declining oral intake as the disease progresses. The patient's appetite may also be adversely affected by her advanced kidney disease. It is necessary that a caregiver is available for all meals. 

The patient has developed substantial functional impairment requiring assistance with all daily activities; and therefore, it is medically necessary to provide assistance to the patient for all ADLs including those that occur throughout the day and night. The patient needs a caregiver at least through all daytime/evening hours until she is in bed for the night. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for PCA Level ll; 70 hours per week, 10 hours per day, 7 days per week is substantiated.  The insurer's denial is reversed.