Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Pressure Ulcer

Treatment: Increase in Personal Care Aide (PCA) services for a total amount of 168 hours per week (split shift)

The insurer denied coverage for increase in Personal Care Aide (PCA) services for a total amount of 168 hours per week (split shift).

The denial is overturned.

The patient has a history of hypertension, heart disease, deep vein thrombosis (DVT), traumatic subdural hematoma, and dementia who is currently being managed for pressure injury to the right buttock stage III. A Uniform Assessment System (UAS) of New York was performed. This was an interactive video teleconference. The patient lives alone in a 1-bedroom apartment with 12 steps to enter. The patient's grandson lives downstairs.

It is reported by the physician that the patient is bedbound and incontinent as well as suffering a stage III bedsore. The patient requires total assist for bed mobility and transfers. The patient requires total assist for bathing, hygiene and dressing. The patient lives alone and does not have family assistance.

A nursing assessment is reviewed. Braden risk 14. It is reported that the previous stage III is now completely healed. No other pressure injuries or stageable pressure ulcers are present.

A second nursing assessment is also reviewed. Patient now with pressure injury to left and right buttocks, stage II.

A final nursing assessment is also reviewed. It is noted that the patient now has a wound to the right heel. Nursing recommended follow-up with the wound care physician. No signs or symptoms of infection were noted at the wound.

The patient has been advanced to a live-in caregiver, and despite that has an increased wound burden with the recommendation of wound care for reassessment. Given the patient's level of function, comorbidities including dementia, and progressive skin breakdown, an increase in the personal care aide for a total of 168 hours/week split shift is considered medically necessary for the patient. 

"The activities of daily living (ADLs) is a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. The term activities of daily living was first coined by Sidney Katz. ADL is used as an indicator of a person's functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life. Measurement of an individual's ADL is important as these are predictors of admission to nursing homes, need for alternative living arrangements, hospitalization, and use of paid home care. The outcome of a treatment program can also be assessed by reviewing a patient's ADLs" (Edemekong, P. F. et al.).

"Home care (HC) workers provide essential health and personal care supportive services that enable people to live at home rather than receive care in a nursing home or other facility. The great majority of those who receive HC are people over age 65 years, as well as those of all ages with illness or disabilities" (Quinn, M. M. et al.).

"While family caregivers have traditionally provided care for older adults with chronic conditions and disabilities, the demand for paid home care workers has increased in the last decade. Although typically thought to assist with personal care, emerging data suggest that paid home care workers assist with a wider scope of care. However, the extent and quality of the care they deliver remains poorly understood" (Sterling, M. R. et al.).                                             

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in Personal Care Aide (PCA) services for a total amount of 168 hours per week (split shift) is substantiated.