Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, cerebrovascular accident, insomnia, depression, wandering, incontinence

Treatment: Personal care assistance increase from 56 to 84 hours weekly

The insurer denied coverage for personal care assistance increase from 56 to 84 hours weekly.

The denial is overturned.

According to the documentation submitted, this is the case of a patient with a history of dementia, cerebral vascular accident, hypertension, hyperlipidemia, insomnia, depression, breast cancer, GERD (gastroesophageal reflux disease), coronary artery disease, wandering, and incontinence. The patient requested an increase in personal care hours of 56 hours per week to 84 hours per week.

The functional status report for instrumental activities of daily living (IADLs) indicates patient was totally dependent for meal preparation, ordinary housework, managing finances, shopping; the patient also needed maximal assistance for managing medications, phone use, stairs, and transportation.

For activities of daily living (ADLs), the patient needed maximal assistance for bathing, dressing lower body, toilet use; needed extensive assistance for personal hygiene, dressing upper body, walking, locomotion, transfer toilet; and needed limited assistance for eating and bed mobility.

Regarding the patient's cognition, the Uniform Assessment System (UAS) includes diagnosis of vascular dementia. The records provided for review do not include a formal evaluation of the patient's cognition, but the UAS provides some information. As per the UAS, the patient's decision-making for daily tasks is described as moderately impaired - decisions consistently poor or unsafe; cues/supervision needed at all times. The patient was oriented x 1-2; with short term and procedural memory problem. The patient can make their needs known. The patient was not self-directing; and unable to dial 911 or activate personal emergency response system (PERS). The patient's communication ability was noted as difficulty finding words or finishing thoughts, prompting usually needed; the patient misses some intent of message but with repetition or explanation the patient often understands conversation. It was noted that the patient did not respond to questions (regarding mood) from the UAS nurse. Patient history for the UAS was provided by caregiver.

Some behavioral problems were noted. The caregiver reported patient expresses anger at times and can become agitated/resists care (e.g., when eating). Behavioral problems associated with dementia can result in adverse consequences (e.g., falls/injury; interference with care). UAS also reports patient has h/o depression; it was noted the patient has episodes of crying and sad facial expression at times. 

The patient is high risk for falls. Patient-specific risk factors include: unsteady gait, poor balance, dizziness, fatigue, incontinence, cognitive impairment, h/o falls, use of medications associated with fall risk in the elderly (antidepressant, benzodiazepine). Dementia can increase fall risk due to impaired judgement and poor safety awareness. Another concern is the patient's use of clopidogrel which is associated with a higher mortality and complication rate for fall trauma in elderly people.

Recommendation is given to approve for Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes, 84 hours per week.

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 an increase in Personal Care Aide (PCA) services is substantiated.