Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Central Nervous System / Neuromuscular Disorder.
Treatment:  Home Health Care (24 hour/day, split-shift, 7 days/week total 168 hours/week).
The insurer denied 24 hour/day, split-shift, 7 days/week total 168 hours/week.  The denial is overturned in whole.

The patient is a female with past medical history of dementia, osteoporosis, hypothyroidism and osteoarthritis who lives with her husband and had been previously approved for 28 hours/week of personal care assistance (PCA) services (combined 56 hours/week with husband's assigned hours).  There was a request for increase in hours on to 24 hour/day, split-shift, 7 days/week total 168 hours/week.

A Uniform Assessment System - New York Community Assessment Comparison Report tool was performed over the phone and noted patient with increased confusion, especially at night, with two falls in the preceding three months.  Each of the falls occurred at night when the patient typically gets up every 15 minutes to use the toilet.  The patient's daughter reported worsening of patient's diagnosis of dementia.  The patient was assessed at total dependence for tasks of meal preparation, ordinary housework, and shopping, which was unchanged from her previous in-person assessment.

The patient was assessed at extensive assistance for tasks of managing finances, managing medication, phone use, transportation, bathing, dressing upper and lower body, walking, locomotion, transfer toilet, toilet use with tasks of personal hygiene and dressing lower body previously assessed at limited assistance on prior assessment.  Tasks of bed mobility and eating were assessed at limited assistance, previously assessed at supervision only on prior assessment.

The subject under review is the medical necessity for the request for increase in hours to 24 hour/day, split-shift, 7 days/week for a total of 168 hours/week.

The health plan's determination is overturned, in whole.

Yes, personal care services (level 2) 24 hours/day, 7 days/week, split shift to total 168 hours/week, are medically necessary for this patient.

The patient has the diagnosis of dementia with reported progression in her symptoms.  The patient had multiple falls over a periods of 4 months (2 noted on prior assessment tool and 2 more on the recent assessment tool).  Three of the falls occurred at night with noted increase in confusion at night, frequently getting out of bed to use the bathroom.  The patient requires assistance with tasks of walking, locomotion, transfer toilet and toilet use which are occurring frequently in the hours overnight which would not allow for a live-in personal care assistant to have 5 hour of uninterrupted sleep in the 8 hour period of the aide's period of sleep.  Because of the patient's medical condition, she requires assistance with toileting and walking at times that cannot be predicted in the overnight hours.  In addition, there may have been an underestimate of the patient's PCA service needs given that her last assessment had to be performed over the phone and not in person, limiting the ability of the assessor to gauge the patient's walking, locomotion, transfer toilet and bed mobility tasks.