Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dementia, arthritis.
Treatment:  Increase Home Care/Personal Care HHC (Home Health Care) Level 2 .
Per 15 Minutes (mins) To 24 Hours Per Day (split shift).

The insurer denied: Increase Home Care/Personal Care HHC Level 2 Per 15 Mins To 24 Hours Per Day (split shift).  The denial is upheld.

The patient is an elderly male with dementia, arthritis, coronary artery disease, hypertension, and peripheral vascular disease. The request is for an increase in home care/personal care home health care (HHC) level II per 15 minutes to 24 hours per day (split shift). Uniform Assessment System (UAS) evaluation completed recently reflects that the patient required maximal assistance for bathing and dressing. The patient requires extensive assistance with hygiene, toilet transfer and use, and locomotion. He is totally dependent for housework, medication management, and shopping. He is independent for bed mobility, requiring set up only. He is able to eat with limited assistance. A tasking tool completed estimated a need for 46 hours per week of services.
An initial adverse determination letter noted that the request was partially denied. Rather than split shift, the plan approved home care / personal care home health care - level II personal care services, per 15 minutes to 24 hours per day (live in), which was increased from the previous home health care - level II personal care services, per 15 minutes of 63 hours per week. In denying the additional hours, the plan noted that "There has been no change in your clinical condition and no change in your social circumstances. You have no compelling nighttime needs." A final adverse determination letter notes that the patient has no nighttime needs that cannot be addressed "environmentally, behaviorally, and/or pharmacologically."

An appeal letter notes that the patient has urinary and fecal incontinence requiring diaper changes. The letter also notes that the patient has dementia and often yells at night; he is weak and needs repositioning in bed. A physician's note notes that the patient needs "continuous human supervision" due to his medical conditions and inability to complete his activities of daily living independently.

The proposed treatment (increase in home care/personal care home health care level II per 15 minutes to 24 hours per day [split shift]) is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. The request is for an increase in home/personal care to 24 hours per day (split shift). The time-based tool completed recently reflects that allocated time for each of the patient's activities of daily living amounts to 46 hours per week, which is covered by the live-in aide approved by the plan. The submitted documentation does not reflect which activities of daily living cannot be completed with a live-in aide. As the plan correctly notes in their reason for denial, there is no evidence of compelling night-time needs. While the appeal documentation notes urinary and bowel incontinence requiring diaper changes, there is no evidence that environmental, behavioral, and/or pharmacological treatments have failed to address the patient's incontinence. There is no evidence that the patient has night-time needs, which are frequent enough to preclude a live-in aide from obtaining five hours of uninterrupted sleep during an eight-hour period of 
sleep. While the appeal information notes that the patient has confusion at night, personal care services are not covered for supervision and safety concerns, per New York State Guidelines. 

Based on the available information, personal care services with a 24 hour per day live-in aide are sufficient to adequately meet the patient's needs. Thus, the proposed treatment (increase home care/personal care home health care level II per 15 minutes to 24 hours per day [split shift]) is not medically necessary.