Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 

Treatment: Home care/personal care HHC (home health care) - Level 2 personal care services (PCA) of 84 hours per week.

The insurer denied coverage for home care/personal care HHC - Level 2 personal care services of 84 hours per week. 

The denial is overturned. 

This is a female with multiple medical conditions associated with declining functional ability with daily activities. The patient lives alone. She receives personal care services 49 hours per week, provided as Consumer Directed Personal Assistance Services (CDPAS). In the uniform assessment system (UAS), it was noted that CDPAS was provided by the patient's daughter and daughter-in-law. It was not clear whether both or the daughter alone was providing care (as CDPAS). The family reports that the patient's condition has declined and she needs care for more hours per day. 

The patient has several medical conditions contributing to her physical and cognitive functional decline including Lewy body dementia (LBD) which causes substantial functional disability. Compared to other types of dementia (e.g., Alzheimer's disease), LBD causes greater difficulty with motor function, earlier functional decline of activities of daily living (ADLs), and earlier loss of independence. Other problems include visual hallucinations, depression, fluctuations of cognition, sleep disturbances, autonomic dysfunction, orthostatic hypotension and fatigue. Parkinsonian symptoms are also often present. Caring for a person with LBD is often stressful as a result of the high level of care and time commitment needed for assistance with ADLs and instrumental activities of daily living (IADLs) and managing behavioral and emotional problems of the affected person. 

The patient needs substantial help for all toileting related tasks, including walking to the bathroom and transfers; but when she is alone and needs to use the toilet, she must perform all aspects of toileting unassisted. This can increase the time needed to reach the toilet and result in functional incontinence (i.e., inability to reach a toilet in time). Incontinence can occur at any time, especially when the patient is alone and has no assistance going to the toilet or commode. The son reported the patient does not use incontinence products, and so there is no absorption of waste. It appears doubtful that the patient can adequately clean herself and change clothes without assistance. Prolonged skin exposure to wet soiled diapers or clothes can result in incontinence-associated skin damage (e.g., dermatitis, fungal infection). There are incontinence products that have higher absorption and protect against leaks, but it is always preferable to remove soiled incontinence products as soon as possible. The timing and frequency of toileting and incontinence is also variable and generally unpredictable. The patient needs a caregiver to assist with toileting and incontinence throughout the day for protection of her skin, and for safety during toileting related activities, including walking to the bathroom and transfer on/off the toilet. 

There was sufficient evidence to support that the request for an increase in personal care services to 84 hour(s) per week is medically necessary. This will provide the patient with assistance for 12 hours per day (if hours are allocated equally through the week) which will include all IADLs, all the patient's meals/snacks, and provide support for routine ADLs (bathing, dressing, personal hygiene) and ADLs that occur throughout the day (transfers, walking, toileting, incontinence care). 

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient. 

The insurer's denial of coverage for the requested Home Care / Personal Care HHC - Level 2 Personal Care Services of 84 hours per week is reversed. Medical necessity is substantiated.