Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major depressive disorder, dementia with behavioral disturbance, and urinary incontinence
Treatment: Increase in personal care aide (PCA) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift) - a total of 168 hours per week
The insurer denied coverage for increase in personal care aide (PCA) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift) - a total of 168 hours per week
The denial is modified.

The patient has chronic medical problems including dementia. She lives with her spouse and has a daughter; both of whom are supportive and involved in her care. The insurer authorized PCA services of 6.5 hours per day, 7 days per week (totaling 45.5 hours per week). Under review is the requested increase in personal care aide (PCA) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift) - a total of 168 hours per week. 

The Uniform Assessment System (UAS) was reviewed. The patient's cognitive status is described as "moderately impaired." She requires maximal assistance for bathing, lower body dressing and toilet use. She is incontinent of bladder and occasionally incontinent of bowel. Extensive assistance is needed for personal hygiene, upper body dressing and toilet transfers. She is able to ambulate around the home with a seated rollator. For comparison, the UAS report supports functional decline for activities of daily living as also reported by the daughter. 

The functional decline is attributed to "tremors, overall weakness, increase episodes of dizziness."   

The patient's functional decline supports the medical necessity of increasing PCA services. Her condition and functional needs are not at a level or unpredictable as to require the requested PCA services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift) - a total of 168 hours per week. The reviewer would agree that the patient may require 24-hour monitoring. However, safety monitoring under personal care services does not include monitoring an individual (e.g. dementia) when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by her supportive family and increasing PCA services to 12 hours/day, 7 days/week for a total of 84 hours. 

From a physical medicine and rehabilitation perspective, the requested increase in personal care aide (PCA) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift) - a total of 168 hours per week is not medically necessary. 

From a physical medicine and rehabilitation perspective, increasing Personal Care Aide (PCA) services to 12 hours/day, 7 days/week for a total of 84 hours is medically necessary. 

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

The insurer's denial of coverage for the increase in personal care aide (PCA) services: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift) - a total of 168 hours per week is modified. 

Personal Care Aide (PCA) services to 12 hours/day, 7 days/week for a total of 84 hours is medically necessary.