Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia

Treatment: Personal care aide (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - for a total of 168 hours per week (split shift)

The insurer denied coverage for personal care aide (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - for a total of 168 hours per week (split shift)

The denial is overturned

This is a patient with chronic medical problems including hypertension, diabetes and progressive Alzheimer's dementia.  The patient lives alone in a private residence.   The patient has a cousin who provides informal care.  The patient was hospitalized recently.  The patient was subsequently transferred to a skilled nursing facility (SNF) for rehabilitation therapy services.  The patient has since returned home.  The insurer increased PCA level 2; from 8.5 to 9.5 hours per day - 7 days per week - for a total of 66.5 hours/week.  The request is for personal care aide (PCA) level 2; 12 hours per day - 7 days per week; 12 hours per day - 7 days/week - for a total of 168 hours/week (split shift), denied by the insurer, leading to an external review. 

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognition was described as "severely impaired."  The patient is reportedly total dependent for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient is also totally dependent for toilet transfer, locomotion and ambulation.  Maximal assistance is reportedly needed for bathing, personal hygiene, dressing, bed mobility and toilet use.  Limited assistance is reportedly needed for eating. The patient reports being frequently incontinent of bladder and bowel. The patient's ability to perform activities of daily living (ADLs) and self-sufficiency have reportedly declined and deteriorated, respectively, over the prior 90 days. There are night logs that indicate the patient is up at least 1-2 times per night needing assistance with transferring and toileting. The medical record states the "member has unscheduled needs for assistance for toileting, transferring and positioning throughout the day and night." There has been 1 reported fall over the prior 30 days.  The patient's functional ability has modestly declined when compared to the previous UAS report.

The patient's clinical condition and functional deficits are at a level and unpredictable as to require the requested personal care aide (PCA) level 2; 12 hours per day - 7 days per week; 12 hours per day - 7 days/week - for a total of 168 hours/week (split shift).  The therapy notes from the skilled nursing facility (SNF) were reviewed.  The patient required moderate assistance for transfer activities and maximal assistance for ambulating with a walker approximately 30 feet.  Activities such as toileting and dressing varied from moderate to maximal assistance.  The patient's functional ability as of discharge from the SNF on 6/11/23, was not submitted for review.  There is also a letter from the patient's treating physician describing the patient's clinical condition and reported need for "24 hours per day, 7 days a week of home health aide (HHA) service."     

The reviewer agrees the patient's functional ability has declined substantially.  The records indicate the patient needs maximal assistance for bed mobility and is frequently incontinent of bladder and bowel. Also noted is the unscheduled nighttime needs which makes 5 hours of uninterrupted sleep highly unlikely.

Based on the above, the insurer's denial must be reversed. 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) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - for a total of 168 hours per week (split shift), services is substantiated.