Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Falls, Mobility Issues
Treatment: Personal care aide level 2: 12 hours per day - 7 days per week - a total of 84 hours per week.
The insurer denied Personal care aide level 2: 12 hours per day - 7 days per week - a total of 84 hours per week.
The determination is overturned.

This is a male patient with a medical history notable for incontinence and mobility issues. The patient is approved for 8 hours per day, 7 days per week (56 hours per week) of level 2 personal care aide services. The patient and his care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan.

A discharge summary was provided for a hospitalization. The patient was hospitalized for weakness and hypotension in the setting of coronavirus disease (COVID) and a urinary tract infection (UTI). He also received a new diagnosis of chronic lymphocytic leukemia (CLL) at the time. He was discharged home in stable condition.

The patient's physician provided a letter of support for this appeal. The letter lists the patient's current medical diagnoses. The letter states that it would be beneficial to increase the patient's home health hours but does not provide any detail on unmet personal care needs.

The patient's neurologist provided a letter of support for this appeal. The letter states that the patient has had progressively worsening dementia and unsteadiness of gait, and now is unable to perform any activities of daily living (ADLs). He will "require an increase in HHA [home health assistant] hours to assist with daily activities." He has been having increasing falls recently while attempting to perform personal care tasks independently. He has also been having episodes that are concerning for the new onset of seizures.

A Uniform Assessment System (UAS) was completed and was available for review. The patient lives alone in a studio apartment. The patient was alert and oriented to person only. Cognition was severely impaired due to vascular dementia. Recall was 0/3 at five minutes; the patient is not self-directing and unable to perform a procedural task. From a functional standpoint, he requires total dependence for nearly all Instrumental activities of daily living (IADLs). For his activities of daily living (ADLs), he requires total dependence for bathing and toilet use. He requires maximal assistance for hygiene, dressing, eating, walking, locomotion, and toilet transfer. He requires extensive assistance for bed mobility. He is frequently incontinent of urine and occasionally incontinent of stool. He uses diapers to manage incontinence care. A task tool recommended 9.5 hours per day to address his personal care needs. At issue is the medical necessity of personal care aide level 2: 12 hours per day- 7 days per week- a total of 84 hours per week.

The requested health service of personal care aide level 2: 12 hours per day- 7 days per week- a total of 84 hours per week is medically necessary for this patient.

The patient has advanced dementia and cannot direct his own care. He is unable to do any activities of daily living, including transfers, eating, and toileting, without hands on assistance. The UAS recommends 9.5 hours per day and he is receiving less than that currently. His personal care needs can be expected to be continuous and unscheduled throughout the day such that the UAS task tool may underestimate his true need. The patient's recent falls are evidence that he is not capable of performing personal care tasks without assistance. Therefore, the increase in personal care hours is medically necessary for this patient.