Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week
The insurer denied Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week.
The determination is overturned.

The patient has a past medical history of bilateral primary osteoarthritis of the knee, coronary artery disease, hypertension, hyperlipidemia, low back pain, abnormality of gait and mobility, diabetes mellitus type 2, urinary incontinence, depression, anxiety, and mild cognitive impairment who was assigned personal care assistant (PCA) services 5 hours/day, 7 days/week to total 35 hours/week base on a telephonic assessment tool performed. The patient was assessed at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, and shopping. The patient was assessed at extensive assistance with tasks of managing medication, stairs, transportation, bathing, and dressing lower body while limited assistance with tasks of phone use, dressing upper body, transfer toilet, and toilet use. With the tasks of walking, locomotion, bed mobility, and eating the patient was assessed as independent.
Notes from the assessment noted that the patient had difficulty with sitting and standing from the bed, had an unsteady gait, used a rolling walker indoors and rollator walker outdoors, was able to ambulate to the toilet but had some difficulty with sitting and standing, had to hold onto the PCA in order to stand, sometimes needed guided assistance with toileting, was unable to hold onto items for longer period of time due to tremor, and lived alone with limited family support in the afternoon and the evening.
There was a request to increase PCA services and the patient underwent a telephonic assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and shopping while maximum assistance with tasks of managing finances, managing medication, stairs, and transportation. The patient was assessed at extensive assistance with tasks of phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. With the tasks of bed mobility and eating the patient was assessed at supervision only. Notes from this assessment stated that the patient had worsening dementia, needed help with moving on and off from the toilet seat and cleaning after toilet use, and walked and transferred with the rolling walker and needed human assistance for indoors. The plan sent an initial adverse determination denial notice denying request to increase PCA services. The denial stated the patient had no change in clinical condition and no change in her social circumstances and the PCA services were sufficient to meet the patient's personal care needs.
The health plan sent a final adverse determination denial notice stating there was no letter of medical necessity of provided with the appeal. The plan increased the PCA hours to 42 hours/week. At issue is the medical necessity of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week.

The requested services are medically necessary.
The patient has documented chronic progressive medical conditions of osteoarthritis and cognitive impairment. The patient requires assistance with all activities of daily living (ADLs) / Instrumental activities of daily living (IADLs) except bed mobility and eating. The patient lives alone and does not have informal support continuously for the hours outside of PCA hours. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met with the current hours and/or adaptive equipment and/or medical supplies. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient requires PCA assistance outside of the hours the patient has formal and informal support. 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, 7 days/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.