Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Other/Dementia
Treatment: Home Health Care
The health plan denied the requested increase in personal care assistance hours. 
The health plan's determination is overturned.

The patient is a female with a past medical history of osteoarthritis, tremor, hearing loss, visual hallucinations, dementia, bowel incontinence, and urinary incontinence who had a request for increased personal care assistance (PCA) hours. The patient had seen her primary care physician (PCP) and office notes documented that the patient has been seeing the PCP for the past 24 years and has progressive and advanced dementia. The note from PCP indicated the patient was wheelchair bound and could not ambulate on her own at all. The letter also indicated the patient had bladder and bowel incontinence and was unable to take care of herself. Lastly, the PCP note stated it was medically necessary to receive 24/7 nursing home healthcare aide in 2-12-hour shifts, 7 days/week. The patient underwent a telephonic assessment, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finance, stairs, shopping, transportation, bathing, and locomotion while maximum assistance with tasks of managing medication, phone use, personal hygiene, dressing upper/lower body, and toilet use. The patient was assessed at extensive assistance with tasks of bed mobility and eating and tasks of walking, and transfer toilet were not assessed as they did not occur. Notes from the assessment stated the patient lived alone, was unable to express goals, was moderately impaired cognitively, was wheelchair bound and wheeled by others, was two-person transfer from bed to wheelchair, stopped using the toilet, and was unable to change incontinence supplies. The insurer sent a final adverse determination denial notice denying a request to increase PCA hours stating it was not medically necessary and did not meet criteria. 

At issue is the medical necessity of the requested increase in personal care assistance hours.

The health plan's determination of medical necessity is overturned, in whole.

Yes, the patient has documented progressive medical conditions of dementia and osteoarthritis. The patient is wheelchair bound and is unable to transfer alone. The assessment tool noted the activity of walking and transfer toilet "did not occur" but reasoning was because the patient is total care for these activities. The notes from the assessment tool indicate the patient required two people for transfer from bed to wheelchair. The patient needs at least extensive assistance with bed mobility. The patient has unpredictable and unscheduled care needs over a continuum of time, including nighttime hours, and the insurer failed to develop a plan to meet these care needs. The increase in PCA hours is not solely for safety and supervision, but to assist the patient with safe completion of activities of daily living (ADLs)/instrumental activities of daily living (IADLs). The patient's care needs cannot be safely met with medical equipment and supplies alone. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. 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.