Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease
Treatment: Personal Care Assistant. The insurer denied the Personal Care Assistant services, 50 hours per week. 
The denial was overturned.

This is a patient with a past medical history of Alzheimer's dementia with severe cognitive impairment, hypertension, osteoarthritis, urinary incontinence, anxiety and depression who had been assigned 41 hours of personal care assistant (PCA) services (7 hours/day, 3 days/week and 5 hours/day, 4 days/week). The patient had been attending adult daycare two days per week. The patient has a history of behavioral disturbances with her dementia and would refuse to go to adult day care or would refuse to get ready to go causing her son to be late or miss work. The patient had a uniform assessment done on  noting she was not self-directing and unable to express needs although oriented times two (x 2). The patient's assistance level was noted to be total dependence for ordinary housework, managing finances, managing medications, shopping, transportation and phone use, while extensive assistance needed for stairs, bathing, personal hygiene, toilet use and dressing upper and lower extremities. The patient had limited assistance needs with walking, locomotion and transfer toilet. The patient was assessed as independent with bed mobility. The health plan sent a final adverse determination denying 50 hours/week of PCA services. The patient's son wrote a letter noting that the patient did not have community resources to care for her when he was at work for 10 hours/day. The patient's geriatrician wrote a letter indicating the patient requires full assistance and supervision with all activities of daily living (ADLs)and instrumental activities of daily living (IADLs). The geriatrician noted that the patient needs assistance over a continuous time course for tasks which cannot be scheduled. The geriatrician also noted that the patient has had worsening symptoms of her dementia with episodes of agitation and behavioral disturbances. The patient's health advocate wrote a letter reinforcing the son's and geriatrician's concerns. The advocate noted that the insurer felt the patient did not need an increase in PCA service hours as these needs were for safety monitoring and companionship. At issue is the medical necessity of an increase in consumer directed personal assistance services-total of 50 hours a week.
The requested services, consumer directed personal care assistance-total of 50 hours are medically necessary. The patient has a history of Alzheimer's dementia with worsening symptoms in the last 6 months. The patient has been having an increase in behavioral disturbances and she has not been able to attend adult day care two days per week which she had been attending. The patient requires PCA services for multiple ADLs and IADLs. The assistance she needs is for supervision of specific ADLs tasks like bathing, personal hygiene, walking, transferring from toilet, eating and incontinence cares.
The patient lives with her son but he is not able to provide informal care during the time he is at work and for 10 hours on the weekend when he needs to take care of his personal and home needs.