Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Home Care / Personal Care HHC - Level 
2 Personal Care Services, per 15 Minutes to 91 Hour(s) per Week
The insurer denied: Increase Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes to 91 Hour(s) per Week
The denial is overturned.

The patient is an elderly female with a history of general debility due to dementia. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 50 hours per week based on Uniform Assessment System (UAS) of last year to 91 hours per week based on Uniform Assessment System of 5 months ago. The health plan denied the request because the patient has shown that her activities of daily living have not changed significantly, she has not fallen, has not been hospitalized, and that her diagnoses have moderately changed with decreased function but that it is medically necessary to continue at the 50 hours per week of personal care aide (PCA).
The additional hours requested are because of the patient's chronic medical conditions, and to help with her activities of daily living (ADLs) as she is unable to manage her medications, prepare meals, bathe, and toilet. Her dementia is getting worse, and she cannot be left alone unsupervised. A review of the records showed that the patient has multiple chronic medical conditions including dementia, hypertension, chronic kidney disease, hyperlipidemia, type 2 diabetes mellitus, insomnia, vertigo, worsening Alzheimer's disease with associated aphasia, moderate memory loss, new tremors, and unsteadiness with decreased balance. Uniform Assessment System-New York (UAS-NY) evaluation of 5 months ago showed that the patient required extensive assistance with mobility, walking, locomotion, transfer toilet, toilet use, and eating and required maximum assistance with upper/lower body dressing, and bathing, while totally dependent for meal preparation, medication management, and housework. Her family support is very good as she lives with her daughter and her family in a private home with 15 steps to enter.

The requested health service is medically necessary.

The requested increase for Personal Care Assistance through Home Health Care (Level 2) from 50 hours per week based on Uniform Assessment System (UAS) of last year to 91 hours per week based on Uniform Assessment System of 5 months ago is medically necessary. Based on the most recent Uniform Assessment System of 5 months ago, the patient was moderately cognitively impaired with supervision required at all times; she required limited assistance with bed mobility and eating, extensive assistance with bathing and upper/lower body dressing, maximal assistance for managing medications, stairs, transportation, personal hygiene, walking, locomotion, toilet transfer, toilet use, and totally dependent for meal preparation, housework, managing finances, and shopping. The reason for denial by the health plan as stated in the clinical information above does not align with the patient's disability features as stated in the Uniform Assessment System of 5 months ago, as stated above. Therefore, the 91 hours per week requested based on the most recent Uniform Assessment System should be approved.