Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia.
Treatment: Personal care services- 24 hours a day, 7 days a week (split shift).
The insurer denied  personal care services- 24 hours a day, 7 days a week (split shift).
The determination is overturned.

The patient has a past medical history of Alzheimer's dementia, urinary incontinence, and hypertension.
There was a request to increase personal care assistant (PCA) services to 24 hours/day, live in or split shift, 7 days/week with a partial approval noted in denial letter that PCA hours would be increased to 9 hours/day, 7 days/week, to total 63 hours/week. There was another request to increase PCA services assessing the patient at total assistance with task of meal preparation while maximum assistance with tasks of ordinary housework, managing finances, managing medications, phone use, stairs, shopping, transportation, equipment management, bathing, dressing upper/lower body, transfer toilet, and toilet use. With tasks of personal hygiene, walking and locomotion, the patient was assessed at extensive assistance while limited assistance with tasks of bed mobility and eating. Notes from this assessment stated the daughter reported cognitive decline in the patient and functional decline over the last 3 months. Notes also stated the patient had had 3 falls in the last 3 months.
The insurer sent an initial adverse determination denial notice denying request to him creased PCA services. The patient's daughter provided a letter to insurer appealing the denial will to increase PCA services. The letter stated the patient requires assistance standing or getting out of bed and eating, etc. The daughter noted when the patient manages to get up alone she often falls or has other problems. The letter also stated the patient goes frequently to the bathroom and in the overnight hours she sits in the same soiled diaper until the aide comes at 9 AM which has resulted in severe bedsores. The daughter's letter also noted the patient was unable to answer any of the questions at the assessment. The daughter also reported that she had spoken to the case manager and on numerous times had been told that the goal is to keep people in their homes and not be placed into a facility. The letter also stated the daughter was unable to help the patient because of her own medical problems. The patient's primary care physician (or provider) (PCP) provided a letter noting patient had progressive decline due to Alzheimer's dementia and had begun manifesting behavioral disturbances including improper toileting and wandering behaviors during the night. The letter also stated the patient must be supervised at all times and require 24-hour home care. On the same date the patient's provider submitted M11Q form.
The insurer sent final adverse determination denial notice denying request to increase PCA services stating it was not medically necessary and the patient did not meet criteria. The denial stated the daughter had reported the patient could not be left alone and was screaming at night and sometimes had aggressive behavior. In addition, the daughter reported the patient had to go to the bathroom at night. The denial also stated the aids do not manage behaviors or medical conditions and the patient should follow-up with her doctor. In addition, the denial stated the patient did not have a medical condition that warranted being up throughout the night, did not have any skin breaks that required repositioning nor any history of skin breakdown. This denial also stated time was not provided for safety supervision, companionship, or when there are no tasks being done. The denial also stated the current hours could be split into shifts to better meet care needs and the patient's family could talk to a care coordinator regarding a social work referral to put an alarm on the door as well as getting a safe return bracelet and could discuss with the care coordinator the nursing home transition and diversion waiver program.
At issue is the medical necessity of personal care services- 24 hours a day, 7 days a week (split shift).

The services are medically necessary. There is documentation from the patient's PCP and daughter that the patient has had a significant decline in cognitive and physical functioning. The daughter has requested an increase in PCA services multiple times. The daughter documents that the patient has bedsores from improper personal hygiene, toileting, and limited bed mobility. 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 requires turning and repositioning frequently such that a personal care aide would be unable to obtain 5 hours of uninterrupted sleep. The patient's care needs cannot be met with medical supplies and adaptive equipment alone. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs)/Instrumental activities of daily living (IADLs). 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, CDPAS/PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.