Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Services: 24 hours a day, 7 days a week (live-in) for a total of 91 hours
The insurer denied Personal Care Services: 24 hours a day, 7 days a week (live-in) for a total of 91 hours.
The health plan's determination is overturned.

This is a female patient with a past medical history of dementia, hypothyroidism, gastroesophageal reflux disease (GERD), coronary artery disease, congestive heart failure, bladder incontinence, hyperlipidemia, hypertension, and peripheral artery disease who had personal care assistant (PCA) services 6 hours/day, 5 days/week and 7 hours/day, 2 days/week to total 44 hours/week.
There was a request to increase PCA services and the patient underwent a video assessment. Notes from the assessment stated the patient lived alone, had an aide 24 hours/day that the patient's family was paying for outside of currently assigned hours, had been admitted to the hospital twice for falls in the previous 6 months, had moderately impaired cognitive skills, had a decline in activities of daily living (ADL) status compared to 90 days ago, and had deterioration of overall self-sufficiency in the last 90 days.
The patient had a supplemental assessment done noting increased assistance with the task of bathing, dressing upper/lower body, transfer toilet, and toilet use. Notes from the care management assessment stated the patient had been having episodes of bowel incontinence. The patient's primary care physician (or provider) (PCP) provided a letter confirming the medical necessity of around-the-clock care 24/7 due to the patient's multiple comorbidities as it was not safe for the patient to be left alone. 
The insurer provided a final adverse determination denial notice continuing to deny the request to increase PCA services. The patient/patient family appealed denial decision. The patient's healthcare advocate submitted a letter requesting an external appeal on behalf of the patient. At issue is the medical necessity of Personal Care Services: 24 hours a day, 7 days a week (live-in) for a total of 91 hours.

The services are medically necessary. There is documentation from the patient's medical provider of medical necessity for the increased PCA services. The plan assumed that the patient had informal support outside of the currently assigned hours which is not the case, as her children are not able to provide informal support. The patient requires at least limited assistance with walking, locomotion, transfer toilet and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). PCA services 24 hours/day, 7 days/week, to total 91 hours/week 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.