Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other- Dementia 
Treatment: Increase in Personal Care Worker (PCW) services from 7 days per week, 8 hours per day; 56 hours per week to 7 days a week, 12 hours per day; 84 hours per week.

The health plan denied: Increase in Personal Care Worker (PCW) services from 7 days per week, 8 hours per day; 56 hours per week to 7 days a week, 12 hours per day; 84 hours per week.
The determination is: Overturned 

The patient is a male with a past medical history notable for dementia, hearing loss, and age-related debility. The patient is approved for 9 hours per day, 7 days per week for a total of 63 hours per week of personal care worker services. The patient and his care team requested an increase to 12 hours per day, 7 days per week for a total of 84 hours per week. 
The patient's physician states that the patient has worsening cognitive decline with short-term memory loss. His ability to care for himself has worsened. The patient's daughter provided a letter of support for this appeal. The letter states that the patient is very unsteady when transferring and ambulating.
The patient had a comprehensive geriatric assessment performed. He had recently been hospitalized for lower extremity cellulitis. He is treated for hypertension, coronary artery disease, hyperlipidemia, benign prostatic hypertrophy with overactive bladder, a prior transient ischemic attack, and a prior hip surgery. His cognitive screen was notable for a mini mental status examination score of 27 out of 30, missing points for date identification and spelling words backwards.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives alone in his home. The patient was alert and oriented to person and place only with forgetfulness noted. For his instrumental activities of daily living, he requires total dependence for housework. He requires maximal assistance for equipment management, transportation, stairs, finances, and meal preparation. He requires extensive assistance for medications and phone use. For his activities of daily living, he requires maximal assistance for bathing and dressing his lower body. He requires extensive assistance for hygiene, dressing his upper body, walking, locomotion, toilet transfer, and toilet use. He requires limited assistance for bed mobility and eating. He was observed walking and transferring using a rollator walker with weight bearing assistance from his personal care worker. He is frequently incontinent of both urine and stool. The assessment reports no fall in the past 30 days, but he did have a fall within the past 90 days. There was no pressure ulcer present. A mini mental state examination score was 21 out of 30, consistent with mild to moderate cognitive impairment. A task tool associated with the assessment recommended 5.4 hours per day, or 37.7 hours per week to address his personal care needs.
At issue is the medical necessity of the increase in Personal Care Worker (PCW) services from 7 days per week, 8 hours per day; 56 hours per week to 7 days a week, 12 hours per day; 84 hours per week.
The health plan's determination of medical necessity is overturned in whole.
The requested health service of Personal Care Worker (PCW) services 7 days a week, 12 hours per day; 84 hours per week is medically necessary for this patient.
The patient requires hands-on personal care assistance for all activities of daily living and instrumental activities of daily living. The documentation suggests that although the patient uses a walker, he still requires weight-bearing assistance for transfers, ambulation, and toileting. The patient's personal care needs can therefore be expected to be frequent and unscheduled throughout the day. His cognitive impairment limits his ability to completely direct his own care. The incontinence episodes will also require unscheduled personal care assistance for management.