Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's Dementia.
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - for a total of 84 hours per week.
The insurer denied Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - for a total of 84 hours per week.  
The denial is partially overturned.

The patient is a female with medical history notable for blindness and Alzheimer's dementia. The patient was approved for 44.5 hours per week of level 2 personal care services (6.5 hours per day, 6 days per week and 5.5 hours per day, one day per week). The patient and her care team requested an increase to 84 hours per week (12 hours per day, 7 days per week). This request was denied by the insurance company and is the subject under review.
A letter of support for this appeal was provided by the patient's treating physician. The physician attests that the patient's current personal care hours are insufficient to meet her needs. They state that she has had increased debility relating to her new diagnosis of dementia, that she needs activities of daily living (ADLs) assistance, and that there is no caregiver at home to help. The physician states that the dementia manifests as poor memory, forgetfulness, and limited insight into her condition which requires frequent cueing and redirection for tasks. This leads to a delay in accomplishing ADLs in a timely manner. The patient uses a rolling walker and has had more difficulties with ambulation. The patient lives alone and does not have family that lives nearby. The physician recommends an increase in her hours, specifically requesting 8 hours per day, 7 days per week.

A Uniform Assessment System (UAS) was completed and was available for review. Cognition was found to be minimally impaired; she was oriented times three with episodes of forgetfulness. Recall was 2/3 after five minutes and she was unable to follow a multi-step command. Mini-Mental State Examination (MMSE) score was 22. From a functional standpoint, she requires total dependence for housework. She requires maximal assistance for meal preparation, managing medications, and managing finances. For her ADL's, she requires maximal assistance for bathing, dressing lower body, walking, locomotion, and toilet transfer. She requires extensive assistance for hygiene, dressing upper body, toilet use, and bed mobility. She is independent with eating. She uses a cane indoors and a walker outside. She is frequently incontinent of urine (daily) and occasionally incontinent of stool. Compared with prior functional assessment, no significant change was noted in her level of assistance required for ADL's and Instrumental activities of daily living (IADLs).

The health plan's determination is partially overturned.

The requested Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - for a total of 84 hours per week is not medically necessary for this patient, however, it is medically necessary for the patient to receive 56 hours per week (8 hours per day, 7 days per week).

The patient's current service hours of 44.5 hours per week is less than the amount recommended by the task tool. Additionally, the patient's physician attested to medical needs for support of ADL's that are not currently being met by this level of aide hours. The number suggested by the treating physician was 56 hours per week, or 8 hours per day. This represents a modest buffer of 15% (percent) over the number of hours recommended by the task tool, which should be viewed as a minimum number of hours in this case. 
There was not sufficient medical evidence provided that the patient requires 12 hours per day for level 2 personal care services.  Additional hours for taking the patient to church functions or for fall prevention would not be covered; security monitoring and companionship are not stand-alone patient care assistance functions.