Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease
Treatment: CDPAS 40 hours per week, and PCA 23 hours per week.  The request is an increase to 7 days per week, 24 hours per day - Split Shift (PCA)
The insurer denied coverage for: CDPAS 40 hours per week, and PCA 23 hours per week.  The request is an increase to 7 days per week, 24 hours per day - Split Shift (PCA).
The denial is : Modified
This is an adult with progressive Alzheimer's disease. The patient was admitted to a skilled nursing facility. The plan is to return home to live with spouse in a private residence. The insurer approved consumer directed personal assistance services (CDPAS) 40 hours per week, and PCA 23 hours per week. The request is an increase to 7 days per week, 24 hours per day - Split Shift (PCA); leading to an external review.

The Uniform Assessment System (UAS), was reviewed. The patient was a resident in a skilled nursing facility at the time of the assessment. The patient's cognition is described as severely impaired. The patient is reportedly total dependent for completing Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, lower body dressing, toilet transfer/use, locomotion and ambulation. Extensive assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility, and eating. The patient is reported as frequently incontinent of bladder and occasionally incontinent of bowel. There have been no reported falls over the prior 90 days. The patient's cognitive and functional ability have declined when compared to previous UAS reports.

The letter from the patient's treating physician describing his clinical condition and reported need for 24 (split shift) care was reviewed.  The provider does not include the associated treatment notes to support his claim of the patient's reported functional incapacity. In addition, therapy notes from the skilled nursing facility would have also been helpful. The documents reviewed do not describe a level of care, medical condition and functional incapacity that requires the requested 7 days per week, 24 hours per day - Split Shift (PCA).

There is agreement that the patient may benefit from additional monitoring; particularly due to his progressive cognitive decline and falls risk. However, safety monitoring under Personal Care Services (PCS) does not include monitoring an individual (e.g., with dementia, falls risk, general weakness) when no other Level I or Level II personal care services task is being provided. This physician would also agree the patient's cognitive and functional ability has declined and support increasing PCA services. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided by maintaining the approved consumer directed personal assistance services (CDPAS) 40 hours per week and increasing personal care aide (PCA) from 23 to 44 hours per week.

Based on the above, the insurer's denial must be modified. 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 increase hours from 63 hours per week (CDPAS 40 hours per week, and PCA 23 hours per week) to 7 days per week, 24 hours per day - Split Shift (PCA) is not substantiated. However, maintaining CDPAS 40 hours/week and increasing PCA 44 hours/week is medically necessary.