Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Personal Care Worker (PCW)Services to 7 Days Per Week x 24 Hours A Day (split shift) of Continuous Care by More Than One Person
The insurer denied: Personal Care Worker (PCW)Services to 7 Days Per Week x 24 Hours A Day (split shift) of Continuous Care by More Than One Person
The denial is upheld.

The member is an elderly male with a history of general debility and general fatigue with many comorbidities including dementia. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 84 hours per week (12 hours per day, 7 days per week) to 168 hours per week (12 hours per day, 7 days per week). The health plan denied the request because he is able to walk 75 feet with a rolling walker requiring minimal assistance, able to transfer with minimal assistance, and requiring minimal assistance with toileting while he can direct his own care with no nighttime needs required. He has been experiencing a decline in his health and ability to perform activities of daily living since contracting COVID-19. Also, he has been in the emergency department five times in the last months. The additional hours requested are because of his chronic medical conditions and to help with his activities of daily living as he requires total assistance with most activities of daily living including dressing, grooming, skin care, toileting, transfer, and ambulating. And also, because he lives alone with no formal or informal support to help with his needs for personal care. Also, the additional hours are needed not only to mitigate the risk of hospitalization and further injury/illness but also to ensure that he can remain living in the community. A review of the records showed that the member has multiple chronic medical conditions including dementia, multiple compression fractures, coronary artery disease status post myocardial infarction and angioplasty/3-vessel bypass, aortic valve regurgitation, diabetes mellitus, atrial fibrillations, hyperlipidemia, carotid artery stenosis, postural hypotension, while on Eliquis (anticoagulant), and chronic congestive heart failure. As of last month in physical therapy, he is minimally cognitively impaired, was able to ambulate 150 feet on a level surface with minimum assistance, required contact-guard for bed mobility and minimal assistance for transfers; Tinetti assessment was 18/28 showing high risk for falls. His family support is very limited as he lives alone, and the daughter comes to visit from another state.

The requested health service is not medically necessary. 

The requested increase for Personal Care Assistance through Home Health care (Level 2) from 84 hours per week (12 hours per day, 7 days per week) to 168 hours per week (24 hours per day, 7 days per week) is not medically necessary because as of last month in physical therapy, he was minimally cognitively impaired, was able to ambulate 150 feet on a level surface with minimum assistance, required contact-guard for bed mobility and minimal assistance for transfers, and Tinetti assessment was 18/28 showing high risk for falls. His family support is very limited as he lives alone, and the daughter comes to visit. 
The reason for denial by the health plan as stated in the clinical information above does align with his disability features as stated in the physical therapy report of last month. The 12 hours will be adequate to help with his essential needs for each day. Therefore, the 84 hours per week (12 hours per day, 7 days per week) approved is adequate. The requested health service is not medically necessary.