Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia
Treatment: Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week - Total Amount of 84 Hours per Week
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week - Total Amount of 84 Hours per Week.
The determination is overturned.

This is a male patient with a medical history notable for Alzheimer's dementia, unsteady gait, heart disease, and urinary incontinence. The patient is approved for 7 hours per day, 7 days per week (49 hours per week) of personal care aide level 2 services. The patient and his care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan.
Emergency department notes were provided for review. The patient presented after a fall when getting out of bed. He is alone when his home health aide is not working and needs to remain in bed. He was evaluated and not found to have any significant bony injury or bleed. He was admitted to the hospital for further care including treatment of acute kidney injury, hypernatremia, and evaluation of possible syncope as a cause of his symptoms.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient was alert and oriented to person and place only; his recall was 0/3 at five minutes but procedural memory was intact. He is able to direct his own care. For his instrumental activities of daily living (IADLs), the patient requires total dependence for meal preparation, housework, and shopping. He requires extensive assistance for finances, medications, stairs, and transportation. For his activities of daily living (ADLs), he requires maximal assistance for bathing, dressing lower body, toilet transfer, and toilet use. He requires extensive assistance for hygiene, dressing upper body, walking, locomotion, and bed mobility. He is frequently incontinent of urine and occasionally incontinent of stool. A task tool associated with the assessment recommended 49 hours per week to address his personal care needs. Compared to a prior UAS, he showed a decline in functional, cognitive, and continence status.
In the request for additional hours, the patient's daughter states that the patient's condition has deteriorated. He lives alone and cannot care for himself any longer. Further, she states that he requires a wheelchair and not a walker as the health plan stated. At issue is the medical necessity of Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week - Total Amount of 84 Hours per Week

The requested health service of Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week - Total Amount of 84 Hours per Week is medically necessary for this patient.
The patient has dementia, mobility difficulties, and incontinence. He lives alone and is not able to perform any activities of daily living without assistance. He cannot toilet or change his incontinence care supplies without assistance. His personal care needs are expected to be continuous and unscheduled throughout the day, therefore, the task tool recommendation for hours cannot be relied on to determine the patient's true level of need. His emergency department visit and hospitalization for a fall when attempting to perform personal care tasks alone are evidence of unmet personal care needs. Failure to address his needs could result in additional falls, skin breakdown, and/or infection. Therefore, the requested increase in personal care hours is medically necessary and reasonable for the patient.