Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's.
Treatment: Home Care/Personal Care, home health care (HHC)-Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift).
The insurer denied the Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift).
The health plan's determination is overturned.

The patient is a female with a history of recurrent falls, vascular and Alzheimer's dementia with a Montreal cognitive assessment (MOCA) of 16 out of 30 and Parkinson's who is mostly bed bound. She needs assistance with personal care, hygiene, locomotion, toileting, ambulation, dressing of upper and lower extremities. She lives with her family members who have full time jobs and cannot provide care to her most of the time. She has help during the daytime but no help during the nighttime. There has been a progression in her dementia. She has had multiple falls recently and one of the falls resulted in vertebral fractures leading to hospitalization. The patient is currently in a rehabilitation center. There is difficulty with the patients discharge from the rehabilitation center due to the lack of 24 hours a day, 7 days a week (24/7) care that is needed due to her increased risk of falls.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient. In the health plan's letter of denial, it is mentioned that the care provided at night is a safety issue and it is not covered by the health plan. The safety concerns are arising from the physical needs such as toileting, locomotion and ambulation. Since she does need several hours of personal assistance for these tasks during the daytime, it is expected that she will need help for these tasks during the nighttime and the resultant injury is because she has no help available. She has some help from the family members, but they are not available around her all the time. 
According to a study the need factors (activities of daily living (ADL's) and Instrumental activities of daily living (IADL's)) were the most important predictors of hours of help. In all the models examining paid and unpaid hours of help, bathing was the most important ADL measure in predicting hours, (as was required for the patient). This was a controlling factor for other ADLs and IADLs for which help was received. According to this study, the informal providers fail to provide as many hours of help to the people to meet their personal assistance needs [1]. Personal assistance services (PAS) typically fall under personal care, domestic services and paramedical services. Personal services included ambulation, bathing, dressing grooming, bathing, feeding etc., other services include cleaning, bedding, laundry, dusting etc. Other related services include preparation of food, meal cleaning, menu planning, transportation, shopping, money management, etc. Paramedical services include administration of medications, bowel regimen, inserting a medical device into body orifices etc. [2,3] The patient needed help for most of the above-mentioned tasks. As per the office of disability employment policy, 2005, PAS could be provided both formally through paid personal assistant hired by a company, agency, or person with disability, and informally by a family member or a co-worker [4]. I reviewed the letters from the family and the patient had minimal help available from the family. Per the United States Department of the Interior Office of The Secretary personal Bulletin No. 17-18, personal assistant provided is an employee or independent contractor whose primary job functions include provision of PAS[3]. The patient did not have this availability at night, she remained at a high risk for falls and trauma.