Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal care aide (PCA) level 2, 8 hours per day- 7 days per week- for a total of 56 hours per week. 

The insurer denied personal care aide (PCA) level 2, 8 hours per day- 7 days per week- for a total of 56 hours per week. 
The determination is overturned. 

The patient has a medical history notable for diabetic peripheral neuropathy with foot numbness, history of transient ischemic attack (TIA), glaucoma, multiple joint arthritis causing difficulties with ambulation, hypertension, diabetes, and recently diagnosed Alzheimer's dementia. The patient is receiving personal care aid (PCA) level 2, currently approved for 8 hours per day 5 days per week for a total of 40 hours per week. The patient's daughter is currently providing additional assistance but will be moving out of state. The patient requested an increase in services to 8 hours per day 7 days per week for a total of 56 hours per week. This request was denied by the health plan. 
Support for the increase in services is provided by a letter by the patient's primary care physician. In this appeal, the treating physician notes that her dementia and ambulatory difficulties cause her to need assistance to complete activities of daily living, including bathing, dressing, and prompting for meal preparation and nutritional support. The provider believes that due to the nature of these conditions, in-home assistance 7 days per week is medically necessary. Office visit notes from the treating physician were reviewed. These notes support the worsening difficulties with ambulation and caring for herself in her activities of daily living, as well as worsening dementia. 
A request for an increase in services was initiated by the patient's daughter, who is currently involved in the patient's care but who will be moving away. A recent fall (no significant injury noted) was a factor in the request for additional assistance. The patient lives alone in a two-bedroom apartment in an elevator accessible building. The patient's needs are currently being met through a combination of personal care and medical equipment to include a cane, bedside commode, walker, shower chair, and shower bar.
A uniform assessment system (UAS) comprehensive community health assessment was completed. At that time, her cognition was noted to be minimally impaired, but patient was only alert and oriented to person and place. The communication domain was intact. There were no mood disturbances present and no problems with psychological well-being. For her functional status, the patient requires maximal assistance for meal preparation, managing finances, managing medications. She has total dependence for ordinary housework. For activities of daily living, she requires extensive assistance with nearly all, including bathing, dressing, walking, locomotion, and toilet transfer. Toilet use is sufficient with oversight. A caregiver has been providing weight-bearing support for ambulation, locomotion, and toilet transfer. The patient is noted to have episodes of bladder incontinence daily and is continent of bowels. She is currently appropriately using incontinence supplies. 

For comparison, a previous uniform assessment system was completed. Notable differences include the patient's mental status, which was alert and oriented times three originally, but the patient was only oriented times two more recently. Comments under mental status support a generalized advancement of the dementia process in the patient. Assistance level requirements for activities of daily living were largely unchanged. Incontinence was less frequent on the prior evaluation, so this appears to be worsening as well. Episodes of incontinence appear to be correlated to poor glucose control for her diabetes. At issue is the medical necessity of personal care aide (PCA) level 2, 8 hours per day- 7 days per week- for a total of 56 hours per week. 

The requested health service of personal care aid level 2, 8 hours per day 7 days per week for a total of 56 hours per week is medically necessary for this patient. Given the challenges with activities of daily living caused by her ambulatory difficulties, she is not likely to do well without PCA support over the weekends. Additionally, the patient's advancing dementia is complicating all aspects of her care. It is likely that her daughter living nearby has been helping to fill in these gaps. It is not reasonable to expect the patient, who requires this level of assistance for activities of daily living (ADLs), to be able to go through the entire weekend without assistance in these tasks. Her overall health condition could be expected to worsen if she is left unsupervised, as she has an extensive list of medical needs including a somewhat complicated medication regimen. Cueing and oversight would be greatly beneficial for her on the weekends. Additionally, given her frequent episodes of incontinence, she will need assistance on a daily basis to ensure that adequate hygiene is being protected in order to ensure that skin breakdown, urinary tract infections, or yeast infections do not occur due to hygiene issues.