Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal care services (w/o schedule) 10-12 hours a week for a total of 70 hours.
The insurer denied personal care services (w/o schedule) 10-12 hours a week for a total of 70 hours.
The determination is overturned.


This is a male patient with a medical history notable for dementia. The patient is approved for 10 hours per day, 5 days per week and 5 hours per day, 2 days per week (60 hours per week without schedule) of personal care services. The patient and his care team requested an increase to 70 hours per week, and this request was denied by the health plan.
The patient's psychiatrist provided a letter of support for this appeal. The letter states that the patient's physical and emotional condition has deteriorated significantly over the past year. The patient has major depressive disorder and obsessive-compulsive disorder. He is at risk for falls and has had several falls over the prior months. The physician reports unsteady gait and dizziness. He experiences urge incontinence and has difficulty with making it to the bathroom in time. The physician requests an increase in personal care hours.
One of the patient's home health aides provided a letter for this review. The aide cares for the patient Monday through Thursday. The letter states that the patient wears pull ups for incontinence when he is not able to make it to the bathroom in time. The aide leaves his dinner on the table when they leave and the patient does not eat it because he is afraid to walk to the table by himself for fear of falling. The patient only has five hours of assistance on the weekend and when the aide returns on Mondays the patient is very unkempt.
The patient's cardiology nurse practitioner provided a letter of support for this appeal. It states that the patient has coronary artery disease, atrial fibrillation, prior aortic valve replacement and subsequent transcatheter aortic valve replacement (TAVR), heart failure with preserved ejection fraction, chronic kidney disease, and dementia. The provider requests additional home health assistance on the weekends for the patient.
The patient's primary care physician provided a letter of support for this appeal. The letter states that he has a severe gait impairment and dizziness which has led to falls. The physician requests more help at home as he cannot be left alone for any significant period of time.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was not oriented to time. He is able to make some decisions but requires assistance from a caregiver. For his instrumental activities of daily living (IADLs), he requires maximal assistance for meal preparation, housework, shopping, stairs, and transportation. He requires extensive assistance for all others. For his activities of daily living (ADLs), he requires maximal assistance for bathing, dressing, walking, locomotion, toilet transfer, and toilet use. He requires extensive assistance for hygiene. He requires limited assistance for bed mobility and eating. He is occasionally incontinent of urine and continent of stool. A task tool associated with the assessment recommended 43.5 hours per week to address his personal care needs. At issue is the medical necessity of personal care services (w/o schedule) 10-12 hours a week for a total of 70 hours.

The requested health service/treatment of personal care services (w/o schedule) 10-12 hours a week for a total of 70 hours is medically necessary for this patient.
The patient requires hands on assistance for all ADLs and IADLs. He is not able to transfer or toilet without assistance. He is receiving 10 hours per day on the weekdays and 5 hours per day on the weekends, but the case files demonstrate that this lower level on the weekends is causing unmet personal care needs. Five hours would not be expected to be sufficient to meet his needs if he cannot toilet or transfer without assistance. The health plan notes that this should be sufficient based on the task tool recommendation, but in cases where the patient's needs are continuous and unscheduled, the task tool can underrepresent the true need for the patient.