Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular Dementia
Treatment: Home care/personal care (HHC) level 2 personal care services (PCS), per 15 minutes increase to 84 hours/week
The insurer denied HHC level 2 PCS, per 15 minutes increase to 84 hours/week. 
The determination is overturned.

The patient has a history of vascular dementia, chronic pain, degenerative disc disease, urinary incontinence, type 2 diabetes, central vestibular dysfunction, and morbid obesity. The patient was approved for 49 hours/week (7 hours daily) of level 2 personal care services (PCS). The patient's physician requested an increase to a total of 84 hours/week (12 hours/day, 7 days/week) of level 2 PCS. The plan denied this request.

Support for this appeal was provided with a letter from the treating primary care physician. The physician states that the patient requires assistance for getting out of bed, food preparation, and with changing diapers, and therefore would recommend in-home personal care be increased to 12 hours/day.

A letter with recommendations from the treating neurologist was also provided for review. The neurologist states that the patient needs assistance with medications and has a tendency towards self-neglect. They state that she has difficulty with using safety devices because of issues related to prior head injury and longstanding dementia. Because of this, the treating neurologist also recommends an increase to 12 hours/day.

A patient representative wrote a letter on the patient's behalf. The letter states that the patient cannot turn herself or get out of bed independently. Additionally, she is unable to change a diaper independently. They expressed concern that the patient will be in the same position for 17 hours consecutively (in between aide shifts) with a potentially soiled diaper. She also needs reminders for medication and assistance with meal preparation. The representative expressed concern that when the Uniform Assessment System (UAS) was performed that (she reports) the patient was never asked to actually perform the tasks, only if she could do them, and thus she did not actually demonstrate functional ability to the level described in the assessment.

A UAS was completed. The prior assessment was available for comparison. On functional status evaluation, she was noted to require maximal assistance with meal preparation performance, ordinary housework, and shopping. She requires extensive assistance with managing medications and finances. For activities of daily living (ADLs), she requires limited assistance for bathing and dressing the lower body. She was noted to be independent with toilet transfer and use, bed mobility, and eating. She has bladder incontinence less than daily and is continent of stool. According to the evaluation, the "member stated that she was independent with incontinence care." It also states that she has a "supportive daughter/friend who is willing/able to assist during non-service hours" and that this help has been necessary in the recent days for actual ADLs/instrumental activities of daily living (IADLs) performance.

Her medication list was reviewed, which shows some medications are dosed twice daily with both morning and bedtime doses.

At issue is the medical necessity of home care/personal care (HHC) level 2 PCS, per 15 minutes increase to 84 hours/week. 

The requested health service/treatment of HHC level 2 PCS, per 15 minutes increase to 84 hours/week is medically necessary for this patient. There are incongruent reports of the patient's functional status between the UAS and the reports from the primary care physician, neurologist, and patient representative. Per the treating physicians and the representative, the patient's actual functional status appears less than what was described in the UAS. The description of her inability to do her own toileting and need for incontinence care is reasonable justification for the increase in hours by itself. The incongruent report in the UAS may be due in part to the neurological diagnoses described (including dementia) as well as the treating neurologist's report that she has a tendency towards self-neglect. The reports of her current level of function make good justification for the strong medical recommendation by both the primary care physician and the neurologist to increase her PCS. Given her reported functional decline, frequent incontinence, and her need for assistance with medications and eating, extending her PCS is medically necessary.