Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment:  Increase in personal care worker (PCW) service from 7 days per week, 7 hours per day to 7 days per week, 24 hours per day (live-in). 

The insurer denied an increase in personal care worker (PCW) service from 7 days per week, 7 hours per day to 7 days per week, 24 hours per day (live-in). 

The determination is overturned. 

The patient has a past medical history of dementia, hypertension, hyperlipidemia, diabetes mellitus type 2, unsteady gait, neuropathy, osteoarthritis, urinary incontinence, bowel incontinence, osteoporosis, anxiety and depression, gastroesophageal reflux disease (GERD), and history of falls who had been assigned personal care assistant (PCA) services 7 hours a day, 7 days per week, to total 49 hours per week. The patient had a hospitalization for dehydration after several falls. Following that hospitalization, the daughter provided overnight assistance. There was a request to increase PCA hours to 24 hours a day, live-in, 7 days a week. The patient had an assessment tool performed assessing her at maximal assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assisted with tasks of managing finances, managing medication, phone use, stairs, transportation, equipment management, bathing, dressing upper body/lower body, and toilet use. The patient was assessed at limited assistance with tasks of personal hygiene, locomotion, transfer toilet, bed mobility, and eating. 

The notes from the assessment noted patient was not attending social daycare due to the pandemic and that the patient had 2 informal helpers who were able to continue to provide help for the patient. The patient had a Mini-Mental Status Examination scoring 21 out of 30. The patient's daughter provided a letter stating the patient's dementia and incontinence had gotten worse and the patient is not able to care for herself without assistance. The daughter specifically notes that she helps her mother with washing up, bathing, combing her hair, monitoring medication, blood pressure monitoring, blood sugar monitoring, light cooking, cleaning, getting ready for dinner, making sure she eats her meals, making sure she takes her night medication, and helping her 2-3 times per night to get to the restroom while providing incontinent cares as the patient has urinary and bowel incontinence. The daughter indicated that she had to return home and would no longer be able to provide informal help. The patient's son also provided a letter stating he had been helping patient with food shopping, setting up her doctor's appointments, and bringing her to the appointments as she has had deterioration in her health. This letter also stated he is unable to provide informal help at a level that his mother requires due to his job as an essential worker. The son's letter also stated that he found her when she had a recent fall, she was on the floor at the foot of her bed and was covered in stool. 

The patient was evaluated by occupational and physical therapy in her home. It was noted that she required minimal assistance with transfers to and from bed, to and from chair, to and from tub and shower, to and from toilet. In addition, the patient needed minimum assistance with ambulation, bathing, toileting, upper body dressing, lower body dressing, feeding, grooming, physical transfers, meal preparation, housekeeping, shopping, laundry, and oral care. The patient's primary care provider provided a letter stating the patient's medical history and she is not competent to take care of herself and needs help with toileting and incontinence cares. 

The patient's neurologist provided a letter stating the patient's medical conditions and that she was dependent on most activities of daily living and because of worsening neurologic impairment should have extension of her home health services to at least 12 hours per day. The insurer provided a final adverse determination denial notice stating the request to increase PCA services was not medically necessary and the patient did not meet criteria. The letter further stated "You are able to walk and transfer with limited help, use toilet with help of an assistive device, cane. You're able to feed herself the meals that are prepared for you and ahead of time by your PCA. You are able to direct your own care and utilize PERS [personal emergency monitoring system] and there are no unmet nighttime needs identified by the plan at this time". In addition, the denial letter stated that the plan is not required to include safety monitoring as a separate task or to calculate any minutes allotted for safety monitoring as part of the total personal care service hours authorized. The denial letter further states that personal care services, including continuous personal care services, shall not be authorized to the extent that the patient's need for assistance can be met by adaptive or specialized equipment or supplies that can be provided safely and cost effectively. The letter also stated that the patient should continue physical therapy and occupational therapy services and that the authorized service hours can be split in the morning and evening to meet the patient's needs. The patient's healthcare advocate provided a letter noting the medical necessity for increased PCA hours based on clinical standards, medical records, and physician recommendations. This letter also documented the assistance that the daughter was providing the patient since the patient's hospitalization and that the daughter was no longer available to provide informal help. 

At issue is the medical necessity of increase in personal care worker (PCW) service from 7 days per week, 7 hours per day to 7 days per week, 24 hours per day (live-in). 
The services are medically necessary. The patient has documented progressive medical conditions of dementia, osteoporosis, and osteoarthritis with documented worsening of her functional status. The patient had a hospitalization following a fall when PCA was not attending the patient. There is documentation of the patient's increased bowel incontinence and ongoing urinary incontinence. The assessment tool noted the patient required at least some assistance with all activities of daily living (ADLs) instrumental activities of daily living (IADLs). Because the patient has 24 hour care needs the universal assessment total should not have been used to calculate PCA hours. The patient has unpredictable and unscheduled care needs over a continuum of time. The patient's informal helpers are no longer able to provide informal help, specifically, the patient's daughter was returning to her home out of state. Home assessment for occupational and physical therapy also documented the patient's assistance needs with all ADLs/IADLs . The patient's primary care provider and neurologist recommended an increase in PCA hours noting the medical necessity in their letters to insurer. PCA hours for this patient are not solely for safety and supervision but to assist the patient was safe completion of ADLs/IADLs. The patient's care needs cannot be met with adaptive or specialized equipment or supplies. 

The plan did not take into account/document the patient's unscheduled and unpredictable care needs, specifically the need for assistance with bed mobility, locomotion, transfer toilet and toilet use with urinary and bowel incontinence. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.