Central Nervous System
Nursing Services (including Private Duty Nursing)

Diagnosis: Dementia
Treatment: Personal Care Aide
The insurer denied the Personal Care Aide (PCA) Level 2: 12 Hours per Day/7 Days per Week (Total of 84 Hours per Week).
The health plan's determination is overturned.

The patient is a female with past medical history of hearing loss, glaucoma, bowel and bladder incontinence, insomnia, restless leg syndrome, bed bound status, multiple falls, constipation, gastroesophageal reflux disease (GERD), edema, depression, severe dementia, and osteoporosis who had been assigned PCA (personal care assistant) services 8 hours/day, 7 days/week to total 56 hours/week following assessment tool. The patient was assessed at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, and shopping while maximal assistance with tasks of managing medication, phone use, bathing, dressing lower body, walking, locomotion, and transfer toilet. With tasks of personal hygiene, dressing upper body and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of bed mobility and eating.
There was a request to increase PCA services to 12 hours/day, 7 days/week, to total 84 hours/week.

Personal Care Aide (PCA) Level 2: 12 Hours per Day/7 Days per Week (Total of 84 Hours per Week) is medically necessary for this patient.
The patient has documented medical diagnoses that are progressive including dementia, osteoarthritis, hearing loss and glaucoma. The patient requires at least some assistance with all activities of daily living (ADL)/Instrumental activities of daily living (IADL) as noted in both assessment tools. The patient no longer has the same level of assistance with informal help due to her daughter's own medical diagnoses and limitations. The patient would need PCA services outside of the time that her daughter is able to provide care. The plan failed to account for unscheduled and unpredictable care needs that occur over a continuum of time. The patient has bowel and bladder incontinence and requires assistance with tasks of walking, locomotion, transfer toilet, and toilet use all of which are unpredictable and unscheduled care need. An increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. 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.