Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia (other than Alzheimer's disease) along with coronary heart disease, congestive heart failure, anxiety, depression, cancer, and diabetes mellitus. 
Treatment: dementia (other than Alzheimer's disease) along with coronary heart disease, congestive heart failure, anxiety, depression, cancer, and diabetes mellitus. 

The insurer denied coverage for Personal Care Aide (PCA) services 12 hours per day, 7 days per week. 

The denial is overturned. 

 This case involves an elderly patient regarding a reduction in personal care aide (PCA) hours.  An assessment was conducted stating that the patient lives alone in a private dwelling.  She was free from falls and was minimally impaired in terms of decision-making capabilities.  She had memory problems and had some mild difficulty communicating in terms of understanding or being understood.  Patient remains social with family and friends.  She was totally dependent for meal preparation, ordinary housework, managing finances, needed extensive assistance with managing medications, phone use, navigating stairs, was totally dependent for shopping and transportation, and required extensive assistance with bathing.  She needed limited assistance with personal hygiene and dressing the upper body and required extensive assistance with dressing the lower body.  She needed limited assistance with walking, locomotion, toilet use with supervision needed during bed mobility.  She was independent for eating and walked using an assistive device.  The report indicated the patient was able to tolerate the duration of method of transportation to access community-based programs and other medical services outside the home.  She had frequent bladder incontinence but no bowel incontinence.

Her primary diagnosis was dementia (other than Alzheimer's disease) along with coronary heart disease, congestive heart failure, anxiety, depression, cancer, and diabetes mellitus. 

Personal care aide services (PCA) allow patients to remain in the comfort of their own home to receive care/treatment rather than residing in a skilled nursing facility, long-term acute care, or assisted living.  The information provided for the review noted that the patient had a deterioration in her overall functionality.  The assessment noted the patient required assistance with multiple activities of daily living/instrumental activities of daily living and was at risk for falls given her age, deconditioning, and overall functional decline.  She was recently hospitalized for pneumonia, which likely took an additional toll on her body.  She was noted to have mental impairments, which placed her at an increased risk for wandering and possible risk for injury given that she had issues with dizziness and an unsteady gait.  The records noted the patient had bladder incontinence and required assistance with toileting and changing her adult diapers.  In taking the totality of information into consideration, it was determined that an increase to 12 hours/day, 7 days/week of PCA would be reasonable for this individual.  The prior determination is overturned.  The 12 hours/day, 7 days/week of personal care aide is medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Aide (PCA) services 12 hours per day, 7 days per week is substantiated.