Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular dementia
Treatment: Personal care services 12 hours a day, 7 days a week 
The insurer denied Personal care services 12 hours a day, 7 days a week.
The determination is overturned.

The patient has a past medical history of vascular dementia, urinary incontinence, bowel incontinence, hypertension, hyperlipidemia, coronary artery disease, chronic kidney disease, osteoporosis, hearing loss, orthostatic hypotension, and osteoarthritis who had been assigned personal care assistant (PCA) services 9 hours/day, 5 days/week and 4 hours/day, 2 days/week. There was a request to increase the PCA service hours and the patient underwent a telephonic assessment tool assessing the patient at total assistance with tasks of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, managing medication, stairs, shopping, transportation, equipment management, bathing, dressing upper/lower body, and toilet use. The patient was assessed at extensive assistance with the tasks of phone use, personal hygiene, walking, locomotion, and transfer toilet while limited assistance with tasks of bed mobility and eating. Notes from the  assessment stated the patient had 16 falls in 3 months, lived alone, and had moderate cognitive impairment.
The insurer sent an initial adverse determination denial notice denying the request to increase PCA services stating the patient's daughter reported multiple falls, the nurse evaluation noted the patient needed help with bathing, dressing, and making meals, the plan recommended the patient always use her walker to maintain safety, the plan recommended safety precautions, giving more aide hours cannot prevent all falls or injuries, personal emergency response system (PERS) can be used for emergencies, recommended discussing the need for physical therapy with her doctor, recommended splitting PCA hours, and the plan does not provide hours when tasks are not being done.
The insurer sent a final adverse determination denial notice denying request for increased PCA hours. This denial stated the plan provides aide escorts to medical appointments, provides incontinence supplies to assist in keeping the patient clean and dry, provides a commode, recommended the use of grab bars and raised toilet set for safe transfer and safety, the patient had a walker to safely move about her environment, recommended physical therapy (PT), and the plan does not provide time for companionship, safety supervision, or when no tasks are being done.
The patient's memory care physician provided a letter stating the patient had been under their care, the patient has progressive vascular dementia and depressive disorder, over the last months the patient cognitive and physical problems had become worse, the patient became more depressed and anxious with decline in memory, the patient suffers from dizziness and difficulty with walking which leads to her frequent and recurrent falls, and the patient has frequent awaking episodes at night requiring home aide assistance, and the letter stated "It is my professional opinion that she is in need of an increase of her home-care hours to her with activities of daily living (ADL) s during the day and several times at night".
The patient's primary care physician (PCP) provided a letter requesting an urgent increase in hours of home care. The letter stated the patient resides alone, is of very poor functional status, has reduced mobility, walks with assistance of walker and human at maximum of 15-20 steps, has decreased verbal communication, is highly prone to falls and fractures, has chronic severe debilitating pain related to osteoarthritis, has chronic low back pain, has urinary and bowel incontinence and wears diapers requiring multiple daytime and nighttime changes to prevent skin rash and irritation, requires continuous supervision, daily reminders, and assistance, can no longer perform activities of daily living (ADL) s such as cooking, cleaning, bathing, dressing, grocery shopping, lifting objects/reaching overhead, maintaining household, and the provider stated "I recommend and believe it is very important and medically necessary for her to have 24 hours of home care daily, 7 days per week to maintain her current health, and prevent her illness from progressing".  At issue is the medical necessity of personal care services 12 hours a day, 7 days a week.
The services are medically necessary.
The patient has documented progressive medical conditions of vascular dementia, osteoarthritis, osteoporosis, chronic kidney disease, and hearing loss with documented worsening of functional status. The patient requires at least some assistance with all ADLs/instrumental activities of daily living (IADLs). The patient has unscheduled and unpredictable care needs over a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The assessment noted the patient needed maximum assistance with toilet use and extensive assistance with transfer toilet. The patient lives alone. The current hours, medical supplies, and adaptive equipment are not adequate to meet the patient's care needs. An increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7days/week, to total 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.