Appeal type: Medical necessity
Decision: Overturned

Genitourinary/Kidney Disorder/Prostate Problem/Benign prostatic hyperplasia without lower urinary tract symptoms
Home Health Care/Personal Care Aide 7 days x 24 hours
The health plan denied the requested Personal Care Aide 7 days x 24 hours as not medically necessary. The health plan's determination is overturned.

This is a case review for a male with a medical history notable for coronary artery disease, dementia, incontinence, and mobility difficulty. The patient is approved for 10 hours per day, 5 days per week and 6 hours per day, 2 days per week (62 hours per week). The patient and his care team requested an increase to 24 hours per day, 7 days per week (91 hours per week).
The patient's nurse practitioner provided a letter of medical necessity for this appeal. The letter states that the patient has had a rapidly deteriorating mental, physical, and functional status. He has dementia and physical debilities. His status worsened following a COVID-19 infection which led to dyspnea. He requires "constant and continuous supervision and assistance" to help with activities of daily living (ADL). He has urinary incontinence and requires assistance with diaper changes. He requires assistance with transfers and locomotion. For this reason, the provider feels that the increase in hours is medically necessary.
A patient advocate provided a letter of support for this appeal. The letter states that the patient has declined significantly since contracting COVID-19. He is only able to transfer from bed and ambulate with human assistance. He has urinary incontinence and cannot change his own diapers. His personal care aide returns in the morning and finds him soaked in cold urine because the diapers cannot hold 15 or more hours worth of urine and he cannot change his diaper by himself when the aide is not there.
A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted in person. The patient was alert and oriented to person only. He is able to ask for assistance with his needs most of the time but is not self-directing in his care. For his instrumental activities of daily living (IADL), he requires total dependence for meal preparation, housework, finances, and shopping. He requires maximal assistance for medications, phone use, and transportation. For his ADLs, he requires extensive assistance with bathing, hygiene, dressing, and toilet use. He requires limited assistance for walking, locomotion, and toilet transfer. He is independent for bed mobility. Per the review, "member is at risk for fall if allowed to walk unassisted" and "member requires assistance with all aspects of ADLs and IADLs." He is frequently incontinent of both urine and stool and uses pullups for incontinence care. When compared to a prior UAS, the patient showed a cognitive and functional decline across multiple domains.
The patient's medical records were provided and reviewed in detail as part of this review. They reflect the patient's medical status as outlined above.
At issue is the medical necessity for the requested health service/treatment of Personal Care Aide 7 days x 24 hours.

The health plan's determination of medical necessity is overturned, in whole.

The requested health service of Personal Care Aide 7 days x 24 hours is medically necessary for this patient.
The patient has dementia and incontinence. He cannot direct his own care. He relies on human assistance for nearly all IADL and ADL including transfers and toileting. He is not capable of changing his own soiled diapers. By definition, his personal care needs are expected to be continuous and unscheduled in nature. Therefore, 24-hour care is medically necessary and warranted for this patient. Failure to address his personal care needs could result in skin breakdown and/or infection.