Appeal type: Medical necessity
Decision: Overturned



Diagnosis:  Central Nervous System/Neuromuscular Disorder/Other/Dementia of Alzheimer's Type.
Treatment: Home Health Care/Personal Care Services, Level 2: 24 Hours per Day, 7 Days per Week (Split Shift) - Total 168 Hours per Week.
The health plan denied the requested Personal Care Services, Level 2: 24 Hours per Day, 7 Days per Week (Split Shift) - Total 168 Hours per Week as not medically necessary. 
The health plan's determination is overturned.

The patient is a male with a past medical history of dementia, benign prostatic hyperplasia (BPH), hypertension, osteoarthritis, coronary artery disease, seizure disorder, urinary incontinence, gastroesophageal reflux disease (GERD), bowel incontinence, and diabetes mellitus type 2 who had been assigned personal care assistance services (PCA) services 12 hours/day x 5 days/week, and 7 hours/day, 2 days/week, to total 74 hours/week based on assessment performed in person. The patient was assessed at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, shopping, and transportation. With tasks of managing medication, stairs, bathing, dressing upper body, walking, locomotion, transfer toilet, and toilet use, the patient was assessed at extensive assistance while limited assistance with tasks of managing finances, personal hygiene, and dressing upper body. 

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

Yes, there is documentation from the plans own assessments of worsening physical and cognitive functioning. The patient's son provided a letter stating the patient's functional status had changed significantly, since his COVID 19 infection and the patient was unable to ambulate to the bathroom at night by himself and was incontinent of both bowel and bladder and needed frequent, unscheduled, diaper changes throughout the night to prevent wounds. The son also noted the patient has worsening cognitive function and forgets that he is weak and attempts to get out of bed without assistance. Lastly, the son's letter stated he was staying with the patient to accomplish all of the unscheduled tasks that his father had overnight. The son also noted he could not continue to provide this care in the long-term. The patient's psychiatrist provided a letter stating the patient's condition had severely deteriorated during the past few months and the patient had been prescribed medications to control his confusion and overnight awakenings but this had not been helpful. The provider lastly noted the patient needed 12+12 hours of home aide services as medically necessary to help his care, activities of daily living (ADL), and safety. The patient's primary care physician (or provider) (PCP) and home care provider send a letter stating due to the patient's medical conditions the patient had severe limitations of functional and cognitive abilities which made the patient incapacitated and dependent on others for ADLs. The provider also noted the patient had nocturia and needed assistance overnight with frequent diaper changes at least every 4 hours.

Yes, there is documentation from the plans own assessments of worsening physical and cognitive functioning. The requested increase in PCA services is not solely for safety and supervision, but to assist the patient with safe completion of activities of daily living  (ADLs) and instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 per Day, 7 Days per Week (Split Shift) - Total 168 Hours per 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 his own home.