Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, osteoarthritis

Treatment: Personal care aide hours

The insurer is denied coverage for an increase in personal care aide hours from 7 days 24 hours a week (Live-in) to 7 days 2-12 hours a week (split-shift).

The denial is overturned. 

This patient was a female who lived alone in an elevated building status post fall and nursing home discharge. The patient was noted to have memory problem and moderately impaired with making decisions. Total dependence was indicated for meal preparation, ordinary housework, managing finances, stairs, shopping, and transportation. The patient was receiving active treatment for diagnoses of coronary heart failure, dementia, and depression; moderate fatigue was also noted and consistency of pain noted as intermittent. The patient's physician requested an urgent increase in hours of home care due to the patient's rapidly deteriorating mental state and physical health related to advanced dementia, hypertension, bilateral hand and knee osteoarthritis, lumbar spine degenerative disc disease chronic pain, history of failing, and unsteady gait.

The patient has chronic medical conditions resulting in substantial cognitive and physical impairment. Symptoms and behaviors associated with these medical conditions can be difficult to manage (e.g. pain, restricted ROM, agitation, confusion). Pain management in the elderly can be complicated, as adverse effects from medications often limit use. Physical therapy has limited long term value in a person with advanced dementia (inability to learn and retain information). Medications to manage sleep disturbances and agitation may have some efficacy but most have unintended and adverse effects, and must be used with caution. Providing adequate caregiver assistance (e.g. incontinence care, repositioning) can help relieve some types of physical distress and help prevent medical complications (e.g. skin injury, infection). 

Considering the patient's history of chronic pain, nighttime incontinence and severely limited mobility, it is medically necessary for a caregiver to be present throughout the day and night to ensure timely attention to incontinence care; repositioning the patient on a regular basis to relieve pressure; and provide repositioning as needed to help relieve discomfort from musculoskeletal pain. It does not appear that this frequency of care can be provided by a live-in aide, who needs to have at least 5 uninterrupted hours of sleep per day. Although there is no current assessment or nighttime activity log, the UAS plus the patient's history and current information from the patient's physician and community friend provide reasonable confidence that the patient would benefit from continuous PCA services, i.e. 24 hour split shift. An updated UAS and nighttime observation study (activity log) would be helpful. Pending an updated assessment, providing PCA 24 hour split shift services appears to be the better plan to serve the patient's care needs throughout the day and night. 

Based on the above, the medical necessity for an increase in personal care aide hours from 7 days 24 hours a week (Live-in) to 7 days 2-12 hours a week (split-shift) is medically necessary.  The insurer's denial is overturned.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.