Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder - Dementia.

Treatment: Home Health Care. 

The insurer denied increase in personal care services to 24 hours a day 7 days a week (split shift) for a total of 168 hours per week. 

The denial is overturned. 

The patient was a male with past medical history of dementia, anxiety, depression, insomnia, hearing loss, glaucoma, urinary incontinence, bowel incontinence, benign prostatic hyperplasia (BPH), and end-stage liver cancer who had Personal Care Assistance (PCA) services 24 hours/day, live-in, 7 days/week. There was a request to increase PCA services and the patient underwent a telephonic assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, shopping, and transportation while maximum assistance with tasks of phone use, stairs, bathing, dressing lower body, and toilet use. With tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of eating. Notes from the assessment noted the patient had a mutual case with his wife, had a fall and had no informal help. 

The health plan's determination is overturned. 

The increase for personal care services 24 hours a day 7 days a week (split shift) for a total of 168 hours as a shared case with spouse is medically necessary for this patient.
There is documentation of worsening cognitive and physical functioning by both the patient's family and medical providers. The patient no longer has informal help from his wife. The patient has BPH and dementia and is up multiple times at night to use the bathroom and requires assistance with walking, locomotion, transfer toilet, toilet use, and incontinence cares. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Due to the patient's progressive dementia and presumed metastatic liver cancer the patient would not benefit from physical therapy or occupational therapy services. The patient's care needs in the overnight hours are such that a personal care aide would not be able to obtain at least 5 hours of uninterrupted sleep. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 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 his own home.