Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease

Treatment PCA (personal care aide) services of 7 days a week, 2-12 hours per day (split shift)

The insurer denied coverage for PCA services of 7 days a week, 2-12 hours per day (split shift).

The denial is modified.

This female has severe functional impairment due to various medical conditions and is dependent on caregiver assistance for all daily activities. She lives alone. Her son is the only informal caregiver identified. The insurer's final adverse determination denial letter indicates the patient is receiving personal care aide (PCA) services 9 hours per day, plus 4 hours per day from a social service organization. It is noted in the final denial letter that these combined services (13 hours total per day) are allocated daily to provide live-in services. 

The physician's evaluation indicates the patient has severe Alzheimer's disease. There is no formal cognitive evaluation available; but based on the Uniform Assessment System (UAS) (with history from PCA and son) it appears the patient has advanced stage of dementia. As per UAS, the patient's decision-making ability for daily tasks is severely impaired; she is disoriented to person, place and time; has extensive memory loss; easily distracted; episodes of disorganized speech. It is noted that her ability to communicate is limited to simple requests, and she responds only to simple, direct communication. 

Regarding the patient's need for assistance with toileting, the records indicate the patient is incontinent of bladder and bowel (no control present) and is fully dependent on caregivers for all toileting related care. The patient has a foley catheter in place. Physician's letter indicates patient has chronic urinary retention. Another physician's note (telehealth visit) indicated foley was placed due to incontinence (patient noted to have sacral/buttock pressure ulcers). 

The patient has total bowel incontinence. Another reason to have a caregiver present throughout the day and night is for patient comfort. The patient has a few possible sources of pain (joint pain as per visiting nurse notes; pressure ulcers). The patient is dependent on caregivers for bed mobility, and if she is in an uncomfortable position, she relies on the caregiver to reposition her for pain relief. For a person with chronic pain who has very limited ability for self-help for pain control, and impaired ability to communicate with the caregiver, it is necessary to have a caregiver present to help with pain management. Repositioning is one way pain can be relieved through intervention from the PCA.

Clarification was requested from the appealer regarding the status of the 4 additional hours of care provided by the social service organization. The appealer reported that those 4 hours will continue to be available to the patient. Therefore, 4 hours can be deducted from the 24 hours requested for PCA split shift services. The patient will receive personal care continuous services as PCA 20 hours per day (split shift) plus 4 hours from the other provider, total of 24 hours per day, 7 days per week.

The request for Personal Care Aide services, 7 days per week, two - 12 hour shifts per day (split shift) should be upheld. However, Personal Care Aide services 7 days per week, 20 hours per day (split shift) should be approved. 

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Services of 7 days a week, 2-12 hours per day (split shift) is modified. Medical necessity is partially substantiated.