Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Home Health Care. 
The insurer denied the increase in Personal Care Assistance, Level II, 24 hours/day, 7 days/week (split shift) 168 hours per week. 
The denial is overturned in whole.

The patient is a female with past medical history of hypertension, hyperlipidemia, diabetes mellitus (DM) type 2, chronic kidney disease, urinary incontinence, glaucoma, osteoarthritis of the spine, dementia with hallucinations, depression and anxiety who had been assigned personal care assistance (PCA) services 7 hours/day, 7 days/week to total 49 hours/week based on assessment tool. Her Mini-Mental State Examination (MMSE) score was 24/30 at that time. The patient had a follow up office visit with her primary care physician (PCP) noting her urinary incontinence and mild cognitive impairment treated with Namenda. There was a request to increase PCA service hours and the patient had assessment tool performed via the telephone due to COVID pandemic. The reason for assessment was noted to be "significant change in status reassessment". 
The patient's PCA reported the patient uses a pull-up and when the PCA arrives in the morning, the patient is wet, the bed is wet, and the bathroom is wet. MMSE was not performed at this assessment but the report indicates the patient had moderate cognitive impairment. The patient had a telephonic follow up office visit with her psychiatrist for medication adjustment due to dementia with hallucinations. The patient was hospitalized following an unwitnessed fall with injury to her knee. She seen by social work, physical therapy (PT) and not felt to be safe to return home without increased personal care. The son was contacted and did not want her to go to a nursing home due to COVID pandemic and the need for continued cultural support in her own home. In addition, the PCP recommended an increase in hours to 24 hours/day, 7 days/week (split shift) for a total of 168 hours per week so that the patient can remain at home safely and healthy. The medical necessity for the increase in hours is the subject under review.

The requested personal care assistance, Level II, 24 hours per day/7 days per week (split shift), for a total of 168 hours per week is medically necessary for this patient.

The patient has the diagnosis of dementia which is a progressive disease. The patient has complications of this disease with hallucinations and sundowning. The patient is not able to remember if she has eaten and has had weight loss. The patient is not able to manage her medications. The patient was in the process of having medication changes in the outpatient setting when she had a fall with injury and was taken to the emergency department. The patient has urinary incontinence with the inability to perform incontinence cares. The patient had an assessment tool for PCA service hours performed which was performed telephonically and underestimated the patient's assistance needs for meal preparation, managing medication, personal hygiene, toilet use and eating. The patient has unscheduled activities of daily living (ADL) needs in the overnight hours that require the assistance of a PCA. The patient's aide currently leaves at 3 pm and the patient is in the same, now soiled, pull-up when the aide returns in the morning. The patient is at high risk for skin breakdown and infection. The patient lives in a studio apartment without a place for the aide to sleep or obtain 5 hours of uninterrupted sleep during the night. The patient's increased PCA hours are not solely for supervision and safety but to assist the patient in performing ADL's and Instrumental activities of daily living (IADLs). PCA 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 home.