Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, osteoarthritis, heart disease, and urinary tract infections. 
Treatment: Increase Home Care/Personal Care HHC per 15 Minutes to 24 Hours per Day, Live in. 

The insurer denied: Increase Home Care/Personal Care HHC per 15 Minutes to 24 Hours per Day, Live in. 
The denial is overturned. 

This patient is an elderly female with a history including dementia, osteoarthritis, heart disease, and urinary tract infections.  She is appealing denial of increase home care/personal care from 12 hours per day to 24 hours per day, live in.  Uniform Assessment System evaluation completed earlier this year shows severely impaired cognition and functional status: total assistance with housework, managing finances and medications, phone use, shopping; maximal assistance with meal preparation, bathing, personal hygiene, dressing, toilet use, and eating; extensive assistance with toilet transfer; and limited assistance with walking, locomotion, and be mobility.  She has bowel and bladder incontinence. 

An appeal statement from New York State notes that the patient requires assistance throughout the day and night due to incontinence and advancing dementia.  Her provider has stated that she is home bound and requires assistance with activities of daily living (ADLs).  Night logs show that she has two to three unscheduled needs throughout the night, including toileting and bed repositioning.  She is incontinent of bowel and bladder.  

Statements from providers notes that the patient has progressive dementia and requires total assistance with activities of daily living (ADLs).  The patient lives alone and has no informal support.  She has been a patient of hospice earlier this year. 

The proposed treatment, increase in home care/personal care HHC per 15 minutes to 24 hours per day (live in), is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding.  Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  

The patient is appealing denial of increase in home care/personal care from 12 hours per day to 24 hours per day, live in.  The Health Plan denied the request based on the Uniform Assessment System (UAS) evaluation supporting the patient's need for maximal assistance with most activities of daily living.  Uniform Assessment System evaluation completed earlier this year shows the patient requires assistance with all activities of daily living.  She is incontinent of bowel and bladder.  An appeal statement notes that the patient's condition has deteriorated.  She is now in hospice care.  They support her need for assistance with all activities of daily living.  Night logs show that the patient frequently requires assistance with toileting and positioning throughout the night.  She does not have informal support.  The information provided shows that this patient has significant limitations in functioning.  The approved personal care aide 12 hours per day is insufficient to meet this patient's needs for assistance with activities of daily living.  The proposed increase in home care/personal care personal care services 24 hours per day, live in, is medically necessary.