Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Frontotemporal Dementia. 
Treatment: Personal Care Aide (PCA) Services Level 2, per 15 minutes increase to 50 hours per week. 

The insurer denied coverage for Personal Care Aide (PCA) Services Level 2, per 15 minutes increase to 50 hours per week. 

The denial is overturned. 

The patient has frontotemporal dementia (FTD) which was diagnosed years ago. FTD is a progressive neurodegenerative disorder which results in various symptoms including impairment of cognitive function and communication, behavioral changes, and possible movement disorder. His Neurologist noted significant deterioration since initially evaluated years ago. He noted the patient cannot have a conversation; responds with one-word answers.  Also, the patient has significantly impaired short- and long-term memory; he cannot follow directions or communicate his needs. Diagnostic imaging showed severe decrease of tracer activity and severe volume loss in frontal and temporal lobes; noted as consistent with worsening of advanced FTD compared to prior study. 

He lives with his family who have provided informal care. The patient had previously been approved for personal care aide (PCA) services, 12 hours per week. Request for increase of PCA services to 50 hours per week was denied, but the insurer increased services to 36 hours per week. 

The Uniform Assessment System (UAS) report indicates the patient was totally dependent for instrumental activities of daily living (IADLs). For activities of daily living (ADLs) a further decline was noted in the UAS report. The patient needed extensive assistance for bathing, personal hygiene, dressing, toilet use; supervision for walking/locomotion, setup help for toilet transfer, bed mobility and eating. 

The family is concerned about the patient's wandering behavior. Safety supervision and monitoring when assistance is not needed for ADLs is generally not considered part of the scope of care for personal care services. However, this needs to be evaluated in the context of the patient's overall function and risk of harm. Based on the most recent descriptions available of the patient's cognitive status (from UAS and neurologist), the patient has poor judgment and safety awareness and is not capable of calling for help in an emergency situation. The UAS reports the patient cannot be left alone safely. The risks are not only for wandering, but also for falls and various household related accidents that can occur when the patient is alone. This places the aide in a difficult situation. Although the aide's assignment indicates when the shift is over, it appears unreasonable to expect the aide to assume the responsibility of leaving the patient alone when it is apparent that it is not a safe situation. 

The family was a major contributor to his care but now they are less available during work and school hours outside the home. It is medically necessary for another source of caregiver services to replace the care previously provided by the family during the day. Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities, including ADLs that occur at unscheduled and recurring times throughout the day (e.g., toileting, mobility) and other ADLs and household tasks requiring assistance throughout the day.  

Home Care/Personal Care home health care (HHC) - Level 2 Personal Care Services (PCS), per 15 minutes, 50 hours per week are medically necessary. 

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

The insurer's denial of coverage for Personal Care Aide (PCA) Services Level 2, per 15 minutes increase to 50 hours per week is overturned. Medical necessity is substantiated.