Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Cerebral Vascular Accident
Treatment: Home Care/Personal Care Home Health Care (HHC)-Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour (s) per Day (Split Shift)
The insurer denied Home Care/Personal Care Home Health Care (HHC)-Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour (s) per Day (Split Shift).
The denial was overturned.   

This is a male patient with a  medical history of dementia, coronary heart disease, atrial fibrillation, hypertension, hyperlipidemia, CKD, stroke with hemiplegia/hemiparesis, aphasia, dysphagia, gastrostomy, constipation, urinary and fecal incontinence, vit D deficiency, osteoarthritis, dizziness, h/o falling, GERD, s/p pneumonitis, dementia and a cerebral vascular accident in early 2020 resulting in a percutaneous endoscopic gastrostomy. The patient receives bolus feedings several times a day.  The patient lives alone in a one bedroom apartment in a multifamily house. The provided documentation reports that the patient is dependent on caregivers for all IADLs and ADLs, and the UAS indicates patient is never left alone. 

The patient is dependent on caregivers for all IADLs and ADLs. It is not clear who manages the patient's food and medication administration via gastrostomy tube. The patient does not walk and it appears he is in bed most of the time (noted as bedbound in UAS; when in wheelchair he is wheeled by others). All of his personal care needs are managed by caregivers, i.e. the patient does not participate in his ADLs. 

Some daily activities can be scheduled for specific times, e.g. bathing, personal hygiene, dressing. Toileting is not usually a scheduled activity. In this case, the patient is incontinent of bladder and bowel (reported as no control in the UAS); and so the patient is dependent on caregiver assistance for incontinence care throughout the day and night at various and unpredictable times. Inadequate incontinence care can cause incontinence associated skin damage (e.g. dermatitis, fungal infection, increased risk of pressure ulcers). In the video exam of the telemedicine visit, the NP observed scrotal excoriations, which was noted as incontinence dermatitis; and stage 1 and 2 pressure injuries on the sacrum and buttock.

The patient is totally dependent on caregivers for bed mobility. As per the UAS, the daughter has been managing the pressure ulcers and turning him regularly. The NP recommended turning and positioning every 2 hours and routine incontinence care. 
It is not known whether the pressure ulcers are still present or healed. The patient is at risk for new pressure ulcers due to immobility and incontinence. In order to prevent new pressure ulcers, and facilitate healing if there are pressure ulcers still present, it is necessary to turn and position the patient on a regular basis to relieve pressure, and frequently check for incontinence and provide prompt cleaning. Pressure ulcers are associated with pain, risk of infection, and the potential for surgical intervention. It is necessary to implement a plan for pressure ulcer prevention, as the patient's risk factors are most likely not going to change (i.e. immobility, incontinence) due to the patient's chronic medical conditions (stroke, dementia). The NP from the telemedicine visit also recommended an air mattress, which would be helpful, but does not substitute for repositioning on a regular basis. 


Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes, increase to 24 hours per day (split shift) is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Home Care/Personal Care Home Health Care (HHC)-Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour (s) per Day (Split Shift) is substantiated.  The insurer's denial is overturned.