Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/ Neuromuscular Disorder
Home Health Care

Diagnosis-Other- Dementia
Treatment- Personal Care Assistance services 24 Hours per Day (Live-In), 7 Days per Week

The health plan denied Personal Care Assistance services 24 Hours per Day (Live-In), 7 Days per Week
The determination is: Overturned

The patient is a female with medical history notable for blindness, mobility issues, dementia, and urinary incontinence. The patient is approved for 56 hours per week of personal care assistance services. The patient and her care team requested an increase to 24-Hour per day live-in personal care, 7 days per week, for a total of 91 hours per week.

The patient's physician provided a letter of support for this appeal. The letter states that 24-hour care is medically necessary for the patient. She is homebound and unable to direct her own care secondary to dementia. She has advanced macular degeneration which limits her vision and chronic arthritis which has led to gait instability and falls. She requires assistance with toileting, transfers, and using her walker. She has bladder incontinence and requires assistance with both using the bathroom and changing pull-ups. Due to all of these conditions, she requires 24-hour care.

The patient's nurse practitioner provided a letter of support for this appeal. The patient has a diagnosis of major neurocognitive disorder, abnormal glucose levels, prior breast cancer, glaucoma, and memory loss. The letter states that her current level of assistance is not sufficient and that 24-hour per day care is necessary. The patient relies on other individuals for all activities of daily living, including transfers and ambulation. She is at risk for urinary tract infections if she does not have prompt incontinence care.

A Uniform Assessment System was completed and was available for review. The patient was alert and oriented to person only. She is not able to direct her own care. Her cognition was moderately impaired. For her instrumental activities of daily living, she requires maximal assistance for meal preparation, housework, finances, medications, and shopping. She requires extensive assistance for stairs and transportation. For her activities of daily living, she requires extensive assistance for bathing, hygiene, dressing, toilet transfer, and toilet use. She requires limited assistance for walking and eating. She is frequently incontinent of urine and uses about six Pull-Ups per day. She also uses about four chux pads per day. A task tool associated with the assessment recommended 49 hours per week to address her personal care needs.

At issue is the medical necessity of personal care assistance services, 24 hours per day (live-in), 7 days per week.

The health plan's determination of medical necessity is overturned in whole.
The requested health service of Personal Care Assistance Services, 24 Hours per Day (Live-In), 7 Days per Week (Monday through Sunday) is medically necessary for this patient.

The patient has advanced dementia and cannot direct her own care. She requires hands-on assistance for all activities of daily living including toileting and transfers. She is incontinent of urine and requires frequent diaper changes, which she is not able to direct on her own. Her care needs are expected to be continuous and unscheduled throughout the day and occasionally at night as well. Because her needs are continuous, the task tool will not accurately reflect her true level of need. The requested increase to 24-hour live-in care is medically necessary and reasonable for the patient. Failure to provide for her personal care needs could result in falls, skin breakdown, and/or infection.