Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Alzheimer's disease, normal pressure hydrocephalus and diabetes

Treatment: Home Care/Personal Care HHC - Level 2, Personal Care Services, per 15 minutes, increase to 24 hours per day (Live in)

The insurer denied coverage for Home Care/Personal Care HHC - Level 2, Personal Care Services, per 15 minutes, increase to 24 hours per day (Live in)

The denial is modified.

 
This is an elderly female with chronic medical problems including Alzheimer's disease, normal pressure hydrocephalus, and diabetes.  She lives alone in a 2-bedroom apartment.  The patient is approved by the insurer for personal care services (PCS) services 49 hours/week.  A denial of coverage for Home Care/Personal Care HHC - Level 2, Personal Care Services, per 15 minutes, increase to 24 hours per day (Live in) has resulted in an external review. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as moderately impaired.  She is reportedly totally dependent to maximal assistance for performing much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping.  The patient reportedly requires maximal assistance for bathing, lower body dressing, and toilet transfer/use.   Extensive assistance is reportedly needed for personal hygiene, upper body dressing, locomotion, and ambulation.  Limited assistance is reportedly needed for bed mobility and supervision for eating.  The patient is reportedly frequently incontinent of bladder and bowel.  No skin issues were noted, and no nighttime logs were included. 

The patient's functional ability is much the same when compared to the prior UAS report approximately six weeks earlier.  The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the PCS services Home Care/Personal Care HHC - Level 2, Personal Care Services, per 15 minutes, increase to 24 hours per day (Live in).  The patient's recent fall history with resultant hospitalization for subdural hematoma is noted.  This physician would agree that the patient may benefit from additional monitoring; particularly due to her reported cognitive decline and fall risk.  However, safety monitoring under PCS does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided.  Based on the documents reviewed, the patient's functional needs can be appropriately provided and maintained via increasing PCS services to 12 hours/day, 7 days/week total of 84 hours/week.  The patient also has the option of restructuring and flexibly using the 84 PCS hours weekly to better maintain and meet her functional needs.  

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Home Care/Personal Care HHC - Level 2, Personal Care Services, per 15 minutes, increase to 24 hours per day (Live in) services is not substantiated. However, Home Care/Personal Care HHC - Level 2, Personal Care Services, per 15 minutes, increase to 12 hours per day, 7 days/week total 84 hours/week is medically necessary.