Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's
Treatment: Home health care (HHC)

The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: 24 Hours per Day (Split Shift). 
The health plan's determination is overturned.

The patient is a female with past medical history of Alzheimer's dementia, multiple myeloma, diabetes mellitus type 2, urinary incontinence, insomnia, atrial fibrillation on anticoagulation, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and cerebral infarct who had been assigned personal care assistant (PCA) services based on assessment tool performed telephonically assessing the patient at total assistance with task of meal preparation and ordinary housework while maximum assistance with task of managing medication. The patient was assessed at extensive assistance with tasks of managing finances, phone use, stairs, shopping, transportation, equipment management, bathing, and dressing lower body while limited assistance with tasks of personal hygiene, dressing upper body, transfer toilet, and toilet use. With tasks of walking and locomotion the patient was assessed at supervision only while independent with tasks of bed mobility and eating. 

Home Care / Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 Minutes: 24 Hours per Day (Split Shift) is medically necessary for this patient.
There is documentation from the patient's family and PCP (primary care provider) of the patient's deterioration of mental and physical functioning. The patient had increased assistance needs with tasks of bathing, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating when comparing assessments. The patient has 24 hour care needs and the plan improperly used this assessment to calculate PCA hours. The patient's PCP noted the patient required incontinence care frequently due to history of urinary tract infection (UTI). The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to formulate a plan to meet the patient's unpredictable and unscheduled care needs. The patient has medical diagnoses of dementia and insomnia which cause her to be awake during the night with assistance needs over many hours overnight with walking, locomotion, transfer toilet, toilet use, bed mobility, and eating/drinking. The patient's care needs overnight are such that a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. The plan assumed the patient had informal help outside of the hours of PCA coverage and the patient's family is not able to continue informal care outside of the PCA coverage due to their own employment and family obligations. Taking into account plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: 24 Hours per Day (Split Shift) are medically necessary for this patient. Personal care services 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.