Diagnosis: Dementia

Treatment: Personal Care Assistant (PCA) services, Level II, 7 days per week, 24 hours per day, split shift

The insurer denied coverage for PCA services, Level II, 7 days per week, 24 hours per day, split shift.

The denial is overturned.

This case involves a female who has diagnoses including dementia as well as hypertension, osteoarthritis with severe deformity of toes and feet as well as insomnia, urge incontinence and gait impairment. She also suffers from ulcers and atrial fibrillation. She does have a history of falls and lives alone. She is incontinent and unable to ambulate independently. The documentation does indicate she currently receives personal care assistance (PCA) however the aide leaves at 3 pm (post meridiem). She does not receive care until the following morning at 9 am. Documentation indicates due to her worsening condition physically and mentally, she requires help with bathing as well as toileting, dressing, grooming, diaper changes, medical appointments, repositioning, and chores.

This is a female reported to have dementia, insomnia, and advanced degenerative arthritis, frequent falls due to gait impairment and urge incontinence. The clinic notes indicate that she has declined recently and has had frequent falls. She is also reported to need help with all her activities of daily living (ADLs) and help with getting to her doctor's appointments. Her current PCA service of 6 hours a day is grossly inadequate to cover her needs. The information provided is consistent with increased frailty, increased risk for falls with its attendant adverse outcomes. Due to insomnia and toileting issues, she will likely require almost as much help during the night as she would during the day and one provider providing care for both the day and night would not be able to provide this care in a safe manner.

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

The insurer's denial of coverage for the requested Personal Care Assistance (PCA) Services, Level II, 7 days per week, 24 hours per day, split shift is overturned. Medical necessity is substantiated.