Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia

Treatment: Personal Care Aide (PCA), 10 hours per day, 7 days per week - for a total of 70 hours
 
The insurer denied the Personal Care Aide (PCA), 10 hours per day, 7 days per week - for a total of 70 hours.

The denial was overturned.

This is a female patient with has various medical conditions including dementia, hyperglycemia, hypertension, hypercholesterolemia, sciatica, arrhythmia, vertigo, hearing loss, gout, h/o tuberculosis many years ago that contribute to her functional impairment. She depends on caregiver support for all daily activities (IADLs and ADLs). The patient lives alone and is currently approved for 8.5 hours per day personal care aide (PCA) services. The patient's son and physician have identified the need for additional home care hours. A request was made for an increase of PCA services to 70 hours per week. 

Dementia: There are no formal evaluations or details regarding the patient's diagnosis of dementia; but the UAS provides some information. The patient's decision making capacity is impaired to the point where her decisions are consistently unsafe/poor. She has impaired memory (short term, procedural). The caregiver reported patient is increasingly forgetful and confused. She is easily distracted and has episodes of disorganized speech. For a person with dementia, decline in ability to perform daily activities is an expected consequence of the disease as it progresses. 

The patient needs maximal assistance for transfer toilet, and extensive assistance for toilet use, and so it is unlikely the patient can safely and effectively use the toilet or commode when she is alone. In addition, she has frequent episodes of urinary incontinence and occasional bowel incontinence. When the patient is alone, it is unlikely she can quickly go to the toilet or commode when the need occurs considering the difficulty she has with mobility (transfers, walking). 

Proper cleaning after toileting and incontinence care is necessary for the patient's daily hygiene. It is not clear how the patient manages this on her own for (currently) 15.5 hours per day. Inadequate incontinence care can result in incontinence associated skin damage (e.g. dermatitis, fungal infection, increased risk for pressure ulcers). 

The patient needs assistance with transfers and has unsteady gait, requiring maximal assistance for walking. She also needs maximal assistance for dressing, hygiene and toileting. At this level of physical impairment, it appears the aide must be helping the patient to bed before leaving at the end of the 8.5 hour shift. The patient either remains in bed for 15.5 hours each day (through the night) or she attempts to get out of bed unassisted. If she is in bed for such extended periods of time, it is unlikely she has adequate incontinence care through the night. The son reported that the patient is having more frequent falls in the past few months, including an incident when she fell at night, was unable to get up, and was on the floor (soiled from urine and feces) until the aide returned in the morning. 

When the patient has PCA 10 hours per day, there remains a question and concern as to how the patient's care would be managed for the other 14 hours of the day.


Personal Care Aide services 10 hours per day, 7 days per week; total of 70 hours per week are medically necessary.

Based on the above, the medical necessity for Personal Care Aide (PCA), 10 hours per day, 7 days per week - for a total of 70 hours per week is substantiated.  The insurer's denial is overturned.