Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Home health Care - increase in customer directed personal assistance services from 7 days per week live-in to 7 days per week two 12 hour shifts per day (or a split-shift).
The health plan denied the requested increase in customer directed personal assistance services from 7 days per week live-in to 7 days per week two 12 hour shifts per day (or a split-shift) as not medically necessary. 
The health plan's determination is overturned.

The patient is a male with a past medical history of cerebrovascular accident (CVA), coronary artery disease, hypertension, congestive heart failure, constipation, anemia, osteoarthritis, osteoporosis, hypothyroidism, constipation, Alzheimer's dementia, benign prostatic hyperplasia (BPH), hyperlipidemia, urinary incontinence, bowel incontinence, frequent falls, unsteady gait, impaired balance, pressure ulcers, and frequent fungal infections who had been assigned consumer directed personal assistance (CDPAP) program services 24 hours/day, live-in, based on an assessment performed via video assessing patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks and stairs and equipment management. With tasks of managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed extensive assistance while limited assistance with the task of eating. With the task of bed mobility, the patient was assessed at supervision. There was a request to increase CDPAP services and the patient underwent another video assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, phone use, stairs, shopping, and transportation while maximum assistance with tasks of managing medication, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and eating. With the task of bed mobility, the patient was assessed at extensive assistance. Notes from the assessment stated the patient resided with his spouse, had a decline in activities of daily living (ADL) status over the last 90 days and a deterioration of overall self-sufficiency in the last 90 days. 

The health plan's determination of medical necessity is overturned, in whole.

There is documentation from the patient's medical provider of worsening of the patient's physical and cognitive functioning. There is documentation from the plan itself of worsening ADL status and an overall deterioration and self-sufficiency in the last 90 days. The patient has 24-hour care needs. There is documentation from home health agency wound care nurse and the patient's medical provider of nonhealing pressure ulcers. The patient's medical provider has documented medical necessity of repositioning every 2 hours including the overnight hours. The patient also has severe insomnia related to dementia and requires assistance with ADLs in the overnight hours. The patient's care needs are such that a personal care aide would not be able to obtain at least 5 hours of uninterrupted sleep. The requested increase in CDPAP 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). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 12 x 12 hours/day, split-shift, 7 days/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.