Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Home/Personal Care Level 2 24 Hours Day (split shift)
The insurer denied: Increase Home/Personal Care Level 2 24 Hours Day (split shift)
The denial is overturned.

The member is an elderly female with a history of general debility due to dementia with significant functional deficit. The request was for Personal Care Assistance through Home Health care (Level 2) to be increased from 70 hours per week (10 hours per day, 7 days per week) based on the Uniform Assessment System of 4 months ago to 168 hours per week (24 hours per day split-shift, 7 days per week) based on the Uniform Assessment System of 2 months ago. The health plan denied the request because she has enough hours currently authorized in the amount, duration and scope necessary to meet her personal care needs. The additional hours requested are because of her chronic medical conditions, and to help with her Activities of Daily Living (ADLs) as she has cognitive decline and requires extensive assistance with most of her ADLs (Activities of Daily Living) due to significant functional deficit. A review of the records showed that the member has multiple chronic medical conditions including dementia with behavior disturbances, dysphagia, generalized osteoarthritis, frequent falls, history of pelvic fractures, hypertension, hyperlipidemia, atrial fibrillations, anemia, right-hand contracture, aortic valve stenosis, hydrocephalus, scoliosis, myalgia, and history of sepsis. 
Uniform Assessment System for New York evaluation of 2 months ago showed that she was severely cognitively impaired and never or rarely makes decisions, required limited assistance with bed mobility, extensive assistance with eating, maximal assistance for managing medications, stairs, transportation, bathing, personal hygiene, upper body dressing, lower body dressing, walking, locomotion, toilet transfer/use, and totally dependent for meal preparation, housework, managing finances, phone use, and shopping. She lives with her spouse in a private house on the first floor and her daughter lives in the same house upstairs. 

The requested increase for Personal Care Assistance through Home Health care (Level 2) from 70 hours per week (10 hours per day, 7 days per week) to 168 hours per week (24 hours per 
day split-shift, 7 days per week) is medically necessary. 

The requested hours are medically necessary. The member is severely cognitively impaired, and never or rarely makes a decision, requires limited assistance with bed mobility, extensive assistance with eating, maximal assistance for managing medications, stairs, transportation, bathing, personal hygiene, upper body dressing, lower body dressing, walking, locomotion, toilet transfer/use, and totally dependent for meal preparation, housework, managing finances, phone use and shopping. The reason for denial by the health plan as stated in the clinical information above, does not align with her disability features as stated in the UAS (Uniform Assessment System) of 2 months ago. Therefore the 168 hours per week (24 hours per day split-shift, 7 days per week) requested should be approved.