Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Personal Care Aide (PCA) Level 2 Services: 12 hours per day, 7 days per week plus (+) 12 hours per day, 7 days per week (split shift) - total of 168 hours per week.

The insurer denied the Personal Care Aide (PCA) Level 2 Services: 12 hours per day, 7 days per week + 12 hours per day, 7 days per week (split shift) - total of 168 hours per week.  The health plan's determination is overturned.

The patient is a male with a past medical history of dementia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), permanent pacemaker/defibrillator, coronary artery disease, benign prostatic hyperplasia (BPH), chronic anticoagulation, osteoarthritis, lumbar disc disease, bladder cancer, urinary incontinence, bowel incontinence, and depression. He had personal care aide (PCA) services 8 hours/day, 7 days/week based on an assessment performed assessing the patient at total assistance with tasks of ordinary housework, managing finances, and shopping while maximum assistance with tasks of meal preparation, managing medication, equipment management, bathing, dressing lower body, and toilet use. The patient was assessed at extensive assistance with tasks of stairs, transportation, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and bed mobility while set up only with task of phone use and independent with task of eating. The tasking tool estimated 56 hours/week.

The patient was admitted to the hospital with urosepsis and was subsequently readmitted to the hospital with acute respiratory failure. There was a request to increase PCA services and the patient underwent an assessment via video assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, stairs, shopping, transportation, bathing, personal hygiene, toilet use, and bed mobility while maximum assistance with task of dressing lower body. The patient was assessed at extensive assistance with tasks of dressing upper body and eating and it was noted that activities did not occur with tasks of walking, locomotion, and transfer toilet. Notes from the assessment stated the patient lived in a 1-bedroom apartment and had severely impaired cognitive skills.

The patient's cardiologist provided a letter stating the patient required assistance and supervision performing all of his daily activities and it was not recommended that the patient be left alone at any time of the day. The provider also noted the patient required supervision around-the-clock, all hours of the day and night in order to provide a safe and clean environment, optimal nutrition and hydration, prevent falls, injuries, and hospitalization and the patient required repositioning in bed every 2 hours around-the-clock to prevent skin breakdown, bedsores, and contractures. 

There is documentation of the patient's worsening cognitive and physical functioning as well as subsequent decline following 2 hospitalizations. The patient's medical provider documented medical necessity of increased PCA services. The patient's medical provider documented the medical necessity of turning and repositioning at least every 2 hours. The patient requires total assistance with bed mobility per universal assessment. The patient's care needs in the overnight hours would not allow a PCA 5 hours of uninterrupted sleep.

The requested increase in PCA services are not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL's) and Instrumental activities of daily living (IADL's). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 his own home.