Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia without behavioral disturbance, unspecified dementia type, diabetes mellitus, hypertension, anxiety, depression. 

Treatment: Personal care assistance (PCA) services, total of 72 hours per week (weekday/weekend). 

The insurer denied coverage for personal care assistance (PCA) services, total of 72 hours per week (weekday/weekend). 

The denial is overturned. 

This case involves an adult female with a history of dementia without behavioral disturbance, unspecified dementia type, diabetes mellitus, hypertension, anxiety, depression, schizophrenia, and gait instability. She had been calling people in the middle of the night. She was hearing people knocking on the door multiple times a day and opening it. She would wake her husband up in the middle of the night for unclear reasons. She continued to be disoriented to date and time of year. She had some episodes of being mentally unstable. Per the Uniform Assessment System (UAS) - New York Comprehensive Community Health Assessment Report, the patient was receiving 28 hours/week of personal care assistance services. The patient lived with her husband. She was oriented to place and name. She was unable to self-correct. She had episodes of forgetfulness. She required assistance to safely use the phone to contact 911. She required extensive assistance with medication management and finances. She had difficulty finding her words or finishing thoughts. She was unable to fully participate in conversations and make her needs known. She required maximal assistance with meal preparation, managing finances, and managing medications. She required extensive assistance for ordinary housework. She requires extensive assistance with weightbearing support by 1 helper with bathing. She required extensive assistance with personal hygiene and dressing. She requires limited assistance with walking. The patient had impaired range of motion, coordination, and balance due to fatigue and dizziness. The patient had a history of falls. She was frequently incontinent. It was stated that assistance was required for activities of daily living and instrumental activities of daily living. This included urinary incontinence care. 

In this case, the patient had a history of dementia, schizophrenia, and gait instability. She was receiving 28 hours a week of personal care assistant services. She had episodes of forgetfulness. She required assistance to safely use the phone to contact 911. She required extensive assistance with medication management and finances. She had difficulty finding her words or finishing thoughts. She was unable to fully participate in conversations and make her needs known. She required maximal assistance with meal preparation, managing finances, and managing medications. She required extensive assistance for ordinary housework. She required extensive assistance with weightbearing support by 1 helper with bathing. She required extensive assistance with personal hygiene and dressing.  She requires limited assistance with walking. The patient had impaired range of motion, coordination, and balance due to fatigue and dizziness. The patient had a history of falls. It was stated that the patient had functional and physical decline. Her Mini-Mental status exam was 15/30. The patient required increased supervision in activities of daily living and assistance with instrumental activities of daily living. The provider recommended increasing the patient's home health care hours to 12 hours/day. 

Increasing the hours would reduce the physical and mental effects of the patient's chronic conditions and would allow the patient to maintain her current level of independence. Decreasing the patient's hours would likely result in a need for assisted living facility or placement in long-term care. The additional hours are needed to address the patient's declining condition and for safety secondary to her fall risk and dementia. As such, the 72 hours per week of personal care assistance are medically necessary. 

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. 

The insurer's denial of coverage for personal care assistance (PCA) services, total of 72 hours per week (weekday/weekend) is overturned. Medical necessity is substantiated.