Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment:  7 days x 24 hour split shift (2x12) of personal care assistance service (168 hours per week). 
The insurer denied 7 days x 24 hour split shift (2x12) of personal care assistance service (168 hours per week).  
The determination is overturned.

The patient has a past medical history of hypertension, urinary incontinence, dementia, and bilateral deep vein thrombosis (DVT). The patient had been managing the books of a business and her own finances but there was a noted change in her cognitive abilities. The patient had a hospital visit for pneumonia. She had a fall. The patient was seen by neurology with a diagnosis of Alzheimer's dementia versus Lewy body dementia versus Parkinson's disease. The patient was placed on medication for dementia. The patient had increasing agitation, sleeping difficulties, and emotional lability and Seroquel was started. The patient went to the emergency room because of leg pain and was diagnosed with bilateral deep vein thromboses (DVTs) and placed on anticoagulation.
There was a request for personal care assistant (PCA) services and the patient underwent an assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, phone use, shopping, and transportation while maximum assistance with the task of managing medication. With the tasks of stairs, bathing, personal hygiene, dressing lower body, walking, locomotion, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of dressing upper body and transfer toilet. The patient was assessed at supervision with the tasks of bed mobility and eating. Notes from the assessment stated the patient had moderate impairment of cognitive skills. The patient was approved for 42 hours/week of consumer directed personal care assistance program (CDPAP) services.
An office note noted that the patient's family was paying out-of-pocket for the weekend and overnight care. The patient's CDPAP was no longer available and the patient was changed to PCA services. The patient's primary care physician (or provider) (PCP) provided a letter noting that the patient had advanced dementia and was deteriorating rapidly and was now incoherent and oriented times (x) 1 and 4 to 5 hours/week were not adequate and required supervision 24 hours/day 7 days/week. The letter stated without supervision she posed a great risk to health and her environment.
The patient's PCP provided a another letter stating the patient needed assistance with all activities of daily living (ADLs) and required assistance with ambulating, even short distances, was up frequently each night and in distress or with bathroom needs and required an increase in care and requested approval for 24 hours/day, 7 days/week. Due to this progressive cognitive and functional decline, per caseworker notes, the family requested an increase in PCA services to 24 hours a day. Overnight care logs were provided noting that the patient required assistance with ambulation, going to the bathroom, redirection, about every 2-3 hours.
The patient underwent another assessment tool assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with the tasks of managing medication and phone use. With the tasks of stairs, transportation, bathing, personal hygiene, dressing lower body, walking, locomotion, transfer toilet, toilet use, and eating, the patient was assessed at extensive assistance while limited assistance with task of dressing upper body and supervision with task of bed mobility. The insurer provided an initial adverse determination denial notice partially denying request to increase PCA services with an increase to 56 hours/week.
The insurer sent a final adverse determination denial notice denying the request to increase PCA services stating the plan felt the patient's request for an increase in services was for safety and supervision, the patient's living arrangements had not changed, the family paid privately for personal care aide, the patient was receiving incontinence supplies, and the sleep observation report showed she was awake at night and wandering in her home. Overnight care logs noted that the patient required assistance with going to the bathroom and eating and drinking at least every 2-3 hours. The patient's healthcare advocate provided a letter requesting an external appeal of the denial decision to increase PCA services. This letter also stated although the patient's family was paying for aide services on nights and weekends it was no longer financially sustainable and the patient required an increase in PCA services.
At issue is the medical necessity of 7 days x 24 hour split shift (2x12) of personal care assistance service (168 hours per week). 

Yes, the services are medically necessary.
There is documentation of an abrupt change in the patient's cognitive ability with subsequent evaluation and follow-up with a neurologic specialist and optimization of her medications. The patient continued with the progression of cognitive impairment with associated agitation and fractionated sleep as sometimes seen with dementia. At the time of the patient's worsening cognitive function, the family was paying privately for increased aide services outside of those provided by insurer. The patient however required more and more assistance with ADLs and instrumental activities of daily living (IADLs) and it was no longer financially viable for the family to continue to provide PCA services privately. As part of the patient's medical diagnosis of dementia, she has sundowning and sleeping difficulty and while up overnight requires assistance with walking, locomotion, transfer toilet and toilet use. Her assistance needs in the overnight hours are such that an aide would not be able to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies.
Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week are medically necessary for this patient. 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.