Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular Disorder
Home Health Services

Diagnosis: Dementia
Treatment: Increase in personal care services to 84 hours per week 
The health plan denied an increase in personal care services to 84 hours per week 
The determination is overturned.

The patient has advanced dementia, hypertension, diabetes mellitus type 2, anxiety, urinary incontinence, and bowel incontinence who had been assigned personal care assistant (PCA) services 5.5 hours/day, 7 days/week based on an assessment tool. The patient was assessed at total assistance with the task of managing finances and maximal assistance with the tasks of meal preparation, ordinary housework, managing medication, shopping, and transportation. With the tasks of bathing, personal hygiene, dressing upper/lower body, and toilet use the patient was assessed at extensive assistance while assessed at limited assistance with the tasks of phone use and stairs. She was assessed at supervision for tasks of walking, locomotion, bed mobility, and eating.
The patient and/or provider requested an increase in PCA hours to 84 hours/week. The patient's neuropsychiatrist provided a letter stating the patient "is under my care for Alzheimer's disease. She has delusions, severely impaired cognition and has wandered outside her home unaccompanied. Due to her advanced Alzheimer's disease she requires 24 hours/day, 7 days/week care and supervision".
The patient had another assessment tool which assessed the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medications and shopping while assessed at maximal assistance for tasks of bathing, personal hygiene, and dressing lower body. With tasks of phone use, stairs, transportation, walking, locomotion, transfer toilet, toilet use, and bed mobility the patient was assessed at extensive assistance while assessed at supervision only with task of eating. The notes from the later assessment state the patient had a significant change in status and the patient's son gives history that the patient has had progressive worsening of Alzheimer's dementia with worsening memory, hallucinations, and delusions. The insurer sent a final adverse determination notice stating the requested increase in PCA services was not medically necessary but approved an increase in PCA hours to 7 hours/day, 7 days/week to total 49 hours/week. The denial letter states the later assessment indicated abilities to perform physical functioning went down since her prior assessment and additional hours are not provided for companionship, supervision or when tasks are not being performed. The patient was seen by the neuropsychiatrist who noted the patient was unable to provide information, had profound memory loss, remained delusional, was unable to function independently, required constant supervision 24/7, and the physician discussed considering placement in a more supervised setting. 
The increase in personal care services to 84 hours per week is medically necessary.
The patient has documented progression of Alzheimer's dementia and has been noted to have profound/severe symptoms by her provider and through the information on the assessment tool.  The patient had clearly documented worsening of her functional status when comparing her assessment tools.  The patient requires some assistance with all activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) with some of those needs being unpredictable and unscheduled over a continuum of time.  The patient would need PCA services hours provided outside of the time the patient has informal support.  Personal care service hours 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.  Therefore, the increased personal services are medically necessary.