Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal care assistance. 

The insurer denied Home Care/Personal Care HHC - Level 2 Personal Care Services per 15 Minutes: Requested Increase to 84 Hour(s) per Week. 

The health plan's determination is overturned. 

The patient is a female with past medical history of coronary artery disease, aortic insufficiency, ischemic cardiomyopathy, hypertension, hyperlipidemia, rheumatoid arthritis, Sjogren's syndrome, osteoporosis, blindness, hearing loss, dementia, discoid lupus, bladder incontinence, bowel incontinence, factor V Leiden mutation chronically anticoagulated, hypothyroidism, and anemia who had been assigned PCA (personal care assistant) services. The patient underwent a recent assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, bathing, dressing lower body, and toilet use while maximum assistance with tasks of managing medication, phone use, dressing upper body, transfer toilet, and bed mobility. The patient was assessed at extensive assistance with tasks of personal hygiene and eating. The activity of walking did not occur per assessment. Notes from the assessment stated the patient resided at skilled nursing facility, was moderately cognitively impaired, and used a manual wheelchair pushed by others. 

Home Care/Personal Care HHC - Level 2 Personal Care Services per 15 Minutes: Requested Increase to 84 Hour(s) per Week is medically necessary for this patient.
The patient had documented worsening in physical and mental functioning by her medical providers following her fall and hospitalization. The plan incorrectly stated there was no change in physical functioning with bed mobility, bathing, personal hygiene, dressing upper/lower body, walking, eating, meal preparation, ordinary housework, and medication management. Comparing assessments, the patient had a change in functioning with bed mobility (independent to maximum), bathing (extensive to total), personal hygiene (limited to extensive), dressing upper/lower body (limited/extensive to maximum/total), walking (supervision to unable), eating (supervision to extensive), meal preparation (maximum to total), and medication management (extensive to maximum). The patient requires assistance with all activities of daily living (ADL)/ Instrumental activities of daily living (IADL). The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to develop a plan to meet those needs. The increase in hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested 12 hours/day, 7days/week, to total 84 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.