Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care (24 hours per day, live-in). 

The insurer denied Home Care/Personal Care Level 2 Personal Care Services, per 15-minute increase to 24 hours per day (live-in). 
The denial is upheld. 

The patient is a female with a past medical history of Alzheimer's disease, hypertension, hyperlipidemia, coronary artery disease, and arthritis. 

She had been assigned personal care assistant (PCA) services based on assessment tool performed, assessing the patient with minimally impaired cognition with no memory problems. Noted to be alert and oriented, forgetful but able to reorient herself. She had no hearing or vision difficulties. She required maximal assistance with task of ordinary housework and extensive assistance with meal preparation. The patient was assessed at limited assistance with task of bathing, independent with personal hygiene, dressing upper body, limited assistance dressing lower body, supervision with walking and locomotion, independent with transfer to the toilet, toilet use, bed mobility and eating. She ambulated using furniture for guarding. She was noted with no change in activities of daily living (ADLs) status in the last 90 days, with no change in self-sufficiency. She was bladder and bowel continent. A total of 17.8 hours was assessed. 

An increase in services was requested, thus she underwent a reassessment, assessing the patient with modified independent cognition with no memory problems. She was noted to be alert and oriented, forgetful but able to reorient herself. She had no hearing or vision difficulties. She required maximal assistance with task of ordinary housework and meal preparation. The patient was assessed at independent with task of bathing, personal hygiene, dressing upper body, dressing lower body, locomotion, transfer to the toilet, toilet use, bed mobility and eating. She ambulated independently. She was noted with an uncertain ADLs status in the last 90 days, with no change in self-sufficiency. She had bladder and bowel continent. A total of 17.8 hours was assessed. 

The patient's primary care provider wrote a letter of medical necessity. The physician stated that the patient has a diagnosis of Alzheimer's and vascular dementia which severely impacts daily functioning and mobility. The physician noted that she needs assistance with most ADLs including bathing, transferring, toileting, and she required assistance with nighttime routines including eating which she forgets to do and has been noted to have lost weight. 24-hour care was requested. Her current approved hours are for 30 hours per week. 

At issue is the medical necessity of Home Care/Personal Care Level 2 Personal Care Services, per 15-minute increase to 24 hours per day (live-in). 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Home Care/Personal Care Level 2 Personal Care Services, per 15-minute increase to 24 hours per day (live-in) is not medically necessary for this patient. 

The patient requires assistance with ordinary housework, meal preparation, shopping, and bathing. There has not been any noted significant change in functional status. The patient does not appear to require any assistance with frequent toileting, turning, and other overnight tasks that may require 24-hour care. There was no new documentation regarding recommendations for additional aide services which would be medically necessary for the patient above and beyond those documented with the previous nursing assessments. Thus, increased hours are not medically necessary per documentation provided. 

Therefore, the requested health service/treatment of Home Care/Personal Care Level 2 Personal Care Services, per 15-minute increase to 24 hours per day (live-in) is not medically necessary.