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202108-140981

2021

Integra MLTC, Inc.

Managed Long Term Care

Mental Health

Home Health Care

Medical necessity

Overturned

Case Summary

Diagnosis: Alzheimer's disease with anxiety

Treatment: Personal care aide (PCA) services of 24 hours per day (split shift)

The insurer denied coverage for personal care aide (PCA) services of 24 hours per day (split shift).

The denial is overturned.

This case involves an elderly male with a history of Alzheimer's disease with anxiety, depression, coronary artery disease (CAD), atrial fibrillation, benign prostatic hyperplasia (BPH), presence of cardiac pacemaker, bilateral hearing loss, insomnia, gastroesophageal reflux disease, abnormality of gait and mobility and vitamin D deficiency. The documentation indicated the patient is often confused and disoriented, as well as anxious and agitated. The patient's daughter also indicated sometimes he will develop severe generalized weakness up to the point of inability to turn himself in bed. The patient completely depends on caregivers in all his activities of daily living and needs supervision 12 hours a day, as well as 12 hours a night, 7 days a week. He requires turning every 2 hours with repositioning and frequent diaper changes to prevent bedsores, as well as pressure ulcers and infection. He has also sustained multiple falls attempting to get up and down on his own. He has a deteriorating physical condition which causes greater limitations in activities of daily living and has become more dependent upon caregivers. The physician indicates he requires assistance at home to prevent a health or safety crisis from developing.

The patient requires total care. He has a high frailty index due to his advanced age and multiple comorbidities. He also has functional quadriplegia in the sense that he requires help even to turn in the bed and he is bedbound. He cannot ask for help because of his cognitive impairment from advanced dementia. He is at high risk for adverse events such as fractures if he falls.

Due to all of the above-mentioned issues, he should qualify for care 24 hours a day, seven days a week. One person alone cannot provide this care because of the total care the patient requires. This care cannot be given by one person because of the patient's needs and it is reasonable to have a 24 hour split shift. The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

Based on the above, the medical necessity for the requested personal care aide (PCA) services of 24 hours per day (split shift) is substantiated. The insurer's denial is overturned.

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