Appeal type: Medical necessity
Decision: Upheld

Alzheimer's Disease
Home Health Care

The patient is a female with multiple medical problems including diabetes mellitus, arthritis and dementia of Alzheimer's type.
The patient requests personal care services 12 hours a day 7 days a week. The patient has been approved for services 7 hours a day 7 days a week for a total of 49 hours per week. These increased services were denied based upon medical necessity. The subject under review is the medical necessity of the increased hours.

The health plan's determination is upheld.

No, the requested health service of personal care services 12 hours a day, 7 days per week is not medically necessary to manage the patient's medical needs. Her needs can be met appropriately with the current allotted time for personal care services.
The patient's daughter requested an increase in personal care services to 12 hours a day because the patient is confused and requires safety supervision. The patient's daughter filed an appeal stating that her health has declined since the last assessment. This includes Alzheimer's disease which makes her difficult to manage her diabetes with hyper and hypoglycemia. She also needs help with going to the bathroom secondary to a knee condition. The patient's daughter explained that she does not arrive home until late from work and therefore needs more assistance.
Nurse evaluation showed that the patient needs help preparing meals, housekeeping, laundry, shopping, managing medicines, dressing, bathing, personal hygiene and toileting.
Her insurance plan noted the following:
Your care management record was reviewed and noted that your care can be met with the current services. Currently the patient lives with her daughter who helps direct her care. Her daughter does make most important decisions for her. She is able to move around on her own. Noting specifically that care is not noted be medically necessary for companionship or safety supervision without any tasking done at the same time.
HELPS assessment report noted that the patient required help with all instrumental activities of daily living (IADLs) and most activities of daily living (ADLs). It was noted patient required a total of 28 hours per week, divided by 7 days for an average of 4 hours per day. The patient is currently being provided with 7 hours a day of care which is in excess of the noted time recommended.
The patient currently lives with her daughter, grandson and that her son visits daily. She is noted to be frequently confused.
The patient ambulates without an assistive device. On the Uniform Assessment System-New York Community Assessment Report, the distance walked without sitting was noted to be between 15 and 149 feet. She requires frequent redirecting secondary to her memory. There is noted infrequent incontinence. There are no noted skin ulcers or wounds.
Additional services for monitoring the patient, secondary to her confusion may be helpful for companionship, but it is not medically necessary. In order for service to be considered medically necessary the personal care aide must be performing a goal driven task such as an ADL or IADL. Additional time for tasks that do not include such services typically are non-covered. According to documentation provided, all her ADLs and IADLs can be appropriately managed with the current allowed time.