Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide services 24 hrs (split-shift) per day, 7 days per week
The insurer denied Personal Care Aide services 24 hrs (split-shift) per day, 7 days per week.             
The determination is overturned.

This is a female patient with a past medical history of dementia, depression, osteoarthritis, urinary incontinence, constipation, hyperlipidemia, and hypertension who had personal care assistant (PCA) services 10 hours/day, 7 days/week, to total 70 hours/week based on an assessment. There was a request to increase PCA services and the patient underwent another assessment assessing the patient at total assistance with tasks of meal preparation and ordinary housework while maximum assistance with tasks of stairs, shopping, and dressing lower body. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, phone use, transportation, bathing, dressing upper body, walking, locomotion, and toilet use while limited assistance with tasks of personal hygiene and transfer toilet. 
The insurer sent a final adverse determination denial notice partially denying the request to increase PCA services by approving services 24 hours/day, live in, 7 days/week. The denial stated the patient's medical provider noted the patient needed to be turned and repositioned every 2 hours but based on the most recent assessment completed, the patient was independent with bed mobility and did not require assistance with that task. An undated letter from the patient's primary care physician (or provider) (PCP) stated an increase in home care services was medically necessary as the patient's medical conditions were worsening and the patient needed frequent assistance with ADLs during the nighttime hours. Another undated letter from the patient's neurologist requested an evaluation for an increase in home care services for the patient as the patient's condition seemed to be worsening, she was more at risk for falls, needed medication to prevent aggressive behavior, and the patient wore diapers and was incontinent and needed more assistance. There was an undated overnight care log noting assistance needs at least every 4 hours, specifically assistance with transfer toilet and toilet use.  At issue is the medical necessity of Personal Care Aide services 24 hrs (split-shift) per day, 7 days per week. 
The services are medically necessary.
There is documentation from the patient's PCP and neurologist of medical necessity of increased PCA services. The overnight care log documented that the patient requires assistance with ADLs (transfer toilet, toilet use, walking, locomotion) at least every 4 hours which would not allow a PCA at least 5 hours of uninterrupted sleep. In addition, the patient's family noted there is not adequate physical space for a PCA who is assigned "live-in" care to have a place to sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/ Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, PCA services 24 hours (split-shift)/day, 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.