Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's Dementia

Treatment: Personal care aide (PCA) / consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - a total of 168 hours per week.

The insurer denied coverage for personal care aide (PCA) / consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - a total of 168 hours per week.

The denial is upheld.

This is an elderly patient with chronic medical problems including hypertension, atrial fibrillation with history of strokes and osteoarthritis. The patient lives with their daughter in a 2-bedroom apartment.  The insurer approved personal care aide (PCA) level 2: 12 hours per day - 3 days per week; consumer directed personal assistance program (CDPAP): 12 hours per day - 4 days per week - a combined total of 84 hours per week.  The request is for personal care aide (PCA)/consumer direct personal assistance program (CDPAP): 12 hours per day - 7 days per week, 12 hours per day - 7 days/week - for a total of 168 hours/week.

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 personal hygiene, dressing and toilet use.  Maximal assistance is reportedly needed for bathing, bed mobility, toilet transfer, locomotion and ambulation.  Extensive assistance is reportedly needed for eating.  The patient is reportedly frequently incontinent of bladder and continent of bowel.  There has been no reported change regarding the patient's activities of daily living (ADL) status or self-sufficiency over the prior 90 days.  There have been no reported falls over the prior 90 days.  The patient's cognitive and functional ability are also much the same when compared to the previous UAS report.  

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the requested PCA/CDPAP: 12 hours per day - 7 days per week; 12 hours per day - 7 days/week - for a total of 168 hours/week as medically necessary.  The reviewer would agree the patient may benefit from additional monitoring, particularly due to their reported severe and progressive cognitive decline.  However, safety monitoring under personal care services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.   

Based on the submitted clinical records, the patient's health and safety are appropriately provided and maintained at home by the approved PCA level 2: 12 hours per day - 3 days per week; CDPAP: 12 hours per day - 4 days per week - a combined total of 84 hours per week;  along with informal care from family.  The patient also has the option of restructuring and flexibly using the 84 PCA/CDPAP hours weekly to better maintain and meet their functional needs.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care aide (PCA) / consumer directed personal assistant program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - a total of 168 hours per week is not substantiated.