Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular Dementia.
Treatment: Increase in personal care services hours to 12 hours (hrs.) a day, 7 days a week.
The insurer denied: Increase in personal care services hours to 12 hours (hrs.) a day, 7 days a week. 
The denial is: Overturned.

The patient is a female with medical history notable for vascular dementia, coronary artery disease, hypertensive heart disease with heart failure, peripheral vascular disease, diabetes mellitus type 2 with complications, and weakness/fragility with high fall risk. The patient was approved for personal care services for 9 hours per day, 7 days per week for a total of 63 hours per week. The patient's care team requested an increase to 12 hours (hrs.) per day, 7 days per week for a total of 84 hours per week. This request was denied by the health plan, and this denial is the subject under review.

A Uniform Assessment System (UAS) was completed and was available for review. It reports that she is only alert and oriented times 1-2 with increasing forgetfulness. The report states that the patient's niece (who is the primary person directing her care) is only intermittently recognized by the patient. It is unclear whether she is capable of calling for help when she is by herself. From a functional standpoint, she requires total dependence for meal preparation, housework, managing finances, and shopping. She requires maximal assistance for managing medications and phone use. For her activities of daily living, she requires total dependence for bathing and locomotion. She requires maximal assistance for hygiene, dressing upper/lower body, toilet transfer, and toilet use. She requires extensive assistance for bed mobility and eating. Her functional status overall has declined in the 2-3 months prior due to progression of her dementia. She is frequently incontinent of both stool and urine (daily episodes of both) and is unable to manage her own incontinence products. An Hours Evaluation for Paraprofessional Support (HELPS) assessment associated with the UAS recommended 67 hours over 7 days per week of personal care services to help with her functional needs.
The subject under review is the medical necessity for the increase in personal care service hours to 12 hours per day 7 days a week.

The health plan's determination is overturned.

The requested health service/treatment of increase in personal care services hours to 12 hours a day, 7 days a week is medically necessary for this patient. This patient has had significant functional decline over the past several months. She is unable to get out of bed and ambulate on her own or take care of her own toileting needs. She has incontinence of stool and urine. It is unclear if she is capable of making her needs known or calling someone in an emergency but given the clinical information this seems unlikely. It is medically necessary to increase her personal care hours. The health plan denied this request on the basis that it would be for safety monitoring and supervision alone, or for higher skilled nursing needs. However, this is not the case; she is unable to tend to her own continence needs which is a specific personal care function. Furthermore, the HELPS assessment recommends 67 hours per week of personal care. She is currently receiving less than this number. This target is really a minimum, and it is likely that it is underestimating her true need based on the unpredictable and frequent nature of incontinence in patients with dementia. Failure to tend to her continence care needs could lead to skin breakdown, ulceration, or infection.