Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension/High Blood Pressure
Treatment: Home Health Care/Personal Care Worker (PCW) services-7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person
The health plan denied the requested increase in the health service/treatment of Personal Care Worker (PCW) services-7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person.
The health plan's determination is overturned.

This is a case review for a female with a medical history notable for advanced dementia, urinary and fecal incontinence, diabetes, and hypersensitivity lung disease. The patient was approved for 7 days per week, 24 hours per day live-in personal care worker services (91 hours per week). The patient's care team requested an increase to 24 hours per day, 168 hours per week continuous care by more than one person.
A letter of support for this appeal was provided by the treating physician. The letter states that the patient lives alone in her apartment and is bedbound. Her cognition has been declining and she has been experiencing sundowning, resulting in yelling, agitation, and confusion in the night. She cannot independently perform any activities of daily living (ADLs) or instrumental activities of daily living (IADLs). She cannot reposition herself in bed. She is incontinent and needs assistance with soiled diapers. The physician attests that these medical needs warrant an increase in personal care services.

A home visit note following an emergency department (ED) visit due to fall was provided for review. Notes state that she is alert and oriented times 2-3 and "very forgetful." She needs help with multiple ADLs and is unable to perform IADLs. She was started on Seroquel at night to help with agitation. Candidiasis was noted under the right breast and in the groin and anti-fungal treatment was ordered.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was found to have severely impaired cognition and was unable to make any decision. From a functional standpoint, she requires total dependence for meal preparation, housework, managing finances, shopping, transportation, and equipment management. She requires maximal assistance for managing medications. For her ADLs, she requires total dependence for locomotion. She requires maximal assistance for bathing, hygiene, dressing upper/lower body, and toilet use. She requires extensive assistance for bed mobility and eating. She is frequently incontinent of both stool and urine. Compared with prior UAS, she showed a decline in most functional domains and has had a new onset of fecal incontinence.

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

The requested health service/treatment of Personal Care Worker (PCW) services-7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person of PCW services is medically necessary for this patient.

The patient has advanced dementia and has become bedbound. She has frequent incontinence of both stool and urine which requires assistance with diaper changes. She requires extensive assistance for bed positioning. Her care needs will occur throughout the day and night and be completely unpredictable. A live-in aide requires continuous, uninterrupted sleep. It would not be appropriate to leave this patient without personal care overnight, as staying in a soiled diaper would result in skin breakdown and/or infection. She has already developed a fungal infection of the groin which is a common precursor to skin breakdown. The additional hours are not simply for safety monitoring and security, as she is likely to have ongoing personal care needs overnight, including toileting, diaper changes, and repositioning in bed for comfort and prevention of pressure ulcers.