Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease
Treatment: Personal care assistance services level 2, 24 hours per day 7 days per week, live in
The insurer denied the Personal care assistance services level 2, 24 hours per day 7 days per week, live in.
The determination is overturned.

The patient has a past medical history of dementia, anxiety, depression, and chronic pain and had been assigned personal care assistance (PCA) service hours 4 hours/day, 7 days/week to total 28 hours/week based on assessment tools performed. The assessment tool assessed the patient at maximal assistance with tasks of meal preparation, ordinary housework, shopping, and transportation while extensive assistance with tasks of managing finances, managing medication and phone use. The patient was assessed at limited assistance with tasks of bathing while supervision only with tasks of stairs, dressing upper/lower body, transfer toilet, and toilet use. She was assessed as independent with tasks of personal hygiene, walking, locomotion, bed mobility, and eating.
The patient's Mini-Mental State Examination (MMSE) was 23/30. The patient's primary care provider (PCP) provided a letter stating the patient's worsening dementia and need for increased supervision and care. This letter also noted the patient is severely decompensating, does not eat her food, hides her food in the bathroom, is unable to perform activities of daily living (ADLs) on her own, and is often at risk of leaving her home unsupervised. There was a request to increase PCA service hours to 24 hours/day x 7 days/live-in. The plan sent a final adverse determination denial notice stating denial of request to increase PCA service hours stating it was not medically necessary, the medical condition was not major, stated the patient was forgetful and in need of 24 hour supervision. The patient had another assessment tool performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, phone use, and transportation. The patient was assessed at extensive assistance with task of bathing and limited assistance with task of personal hygiene, dressing upper/lower body, and toilet use. She was assessed at supervision only for tasks of walking, locomotion, transfer toilet, bed mobility, and eating. The patient's neurologist provided a letter stating the patient's diagnosis of Alzheimer's dementia, moderate, it is a progressive illness, the patient requires assistance with all ADLs, the patient requires prompts, cues, and monitoring to carry out her ADLs, such as toileting and bathing. This letter states the patient's needs are continuous and unscheduled and requires assistance with tasks that occur over a continuous span of time. The patient's family appealed the denial. A consumer advocate for the patient provided a letter of support for external appeal of insurer's denial.  The letter reiterated the plan's denial reasons and the letters from the patient's PCP and neurologist. The advocate's letter stated the patient requires PCA services over a span of 24 hours and therefore task-based assessment tool should not have been performed. The letter also noted the patient does not have an informal caregiver as documented by a letter from the patient's sister. At issue is the medical necessity of personal care assistance services level 2, 24 hours per day 7 days per week, live in.
The services are medically necessary. The patient has the diagnosis of Alzheimer's dementia which is a progressive illness with further documentation from the patient's neurologist of the patient's worsening mental and functional status. Based on the assessment tool, the patient requires at least supervision and limited assistance with tasks of personal hygiene, toilet use, transfer toilet, locomotion, walking, bed mobility and eating. The plan did not acknowledge that the patient does not have an informal caregiver. The patient's PCA services are not solely for safety and supervision but to assist the patient to successfully complete ADLs and instrumental activities of daily living (IADLs). The patient has unscheduled and unpredictable care needs over a continuum of time which the plan did not account for. As stated in the letter from the patient advocate, if the patient's care needs span a 24 hour time frame, state regulations prohibit the plan from using a task based assessment tool. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.