Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.

Treatment: the Personal Care Aide Level 2 services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The insurer denied coverage for the PCA Level 2 services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The denial is overturned.

The patient is a female with a past medical history of Alzheimer's dementia, aphasia, osteoarthritis, anxiety and paroxysmal atrial fibrillation. The patient was hospitalized with dementia and a fall. Discharge instructions included physical therapy services and assistance while ambulating and getting out of bed. The patient was also hospitalized with COVID-19, atrial fibrillation, left sided weakness and debility. The patient received home visiting nurse services, physical therapy and occupational therapy after being discharged from that hospitalization. A telephonic New York State Department of Health's Uniform Assessment System (UAS-NY) was done. The patient and her son were present on the call. The patient lives alone in a 1-bedroom apartment at a senior citizen apartment complex. Per the patient's son, she has a history of wandering prior to being bed bound, and she was found lying outside in the hot sun. The patient's activity of daily of living status has declined, and her overall self-sufficiency has deteriorated. She is totally dependent for meal preparation, ordinary housework, managing finances, managing medications, managing stairs, shopping, bathing, dressing her lower body, walking, locomotion, toilet transfer and toilet use. The patient is occasionally bladder and bowel incontinent, and she wears pull ups. The patient needs maximum assistance with phone use, transportation, personal hygiene, dressing her upper body and bed mobility. She needs extensive assistance with eating. She has mild, intermittent pain which is adequately controlled with her therapeutic regimen. Clinical review checklist shows severe dementia. There has been a decline to maximal assistance/total dependence in dressing, personal hygiene, toilet use, toilet transfer, walking, and bed mobility. 

An increase to personal care aide Level 2 services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is being requested.

The insurer has denied coverage for the personal care aide Level 2 services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.  

The patient's son is appealing. He notes that his mother is completely dependent and cannot be left alone. Her doctor stated that the patient requires 24 hours, 7 days per week of assistance to meet all of her functional needs due to her dementia progression, lethargy and left sided weakness after COVID-19.  

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the insurer's interpretation of the patient's current level of function. 

In the appeal decision, it is noted that the patient has deteriorated in some functions. The Uniform Assessment System of comparison shows substantial decline in multiple parameters as noted above. She does not just need safety monitoring. She now needs maximal assistance or is totally dependent with positioning in bed as well as with almost all other functions. She is incontinent, although infrequently. Her physician has noted that turning and positioning is important in this case. The patient fulfills the criteria for 24-hour care. 

The insurer's denial of coverage for the requested Personal Care Aide Level 2 Services: 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The denial is overturned.