Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:  Personal Care Assistance Services 12 hour per day 7 days per week (Monday through Sunday) a total of 84 hours per week.

The insurer denied Personal Care Assistance Services 12 hour per day 7 days per week (Monday through Sunday) a total of 84 hours per week.  The denial is: Overturned.

The patient is a female with medical history notable for history of cerebrovascular accident, Alzheimer's dementia, and incontinence. The patient is approved for 8 hours per day, 7 days per week (56 hours per week) of personal care assistance. The patient and her care team requested an increase to 12 hour per day, 7 days per week (total 84 hours per week), and this was denied by the insurance company. This denial is the subject under review.

A letter of medical necessity was also provided by the patient's neurologist. The physician states that the patient is totally dependent on home health aides to complete activities of daily living. The physician recommended an increase in home health hours to meet her personal care needs which were described as "constant."

A Uniform Assessment System (UAS) was completed and was available for review. Patient was alert and oriented to person only; cognition was severely impaired. For her functional status, she requires total dependence for meal preparation, housework, managing finances, and equipment management. She requires maximal assistance for shopping, transportation, and managing medications. For her activities of daily living (ADLs), she requires extensive assistance for bathing, dressing lower body, toilet transfer, and toilet use. She requires limited assistance for hygiene, dressing upper body, walking, locomotion, and bed mobility. She resides in an apartment alone and ambulates with a walker and/or wheelchair (of note, the notes from the treating physician state that she is wheelchair bound at this time). The assessment notes that she "is not safe to be by herself due to her current condition and history of frequent falls." She is completely incontinent of urine and occasionally incontinent of stool. She wears pull-ups and requires assistance for changing them. Compared with prior assessment, she showed worsening cognition and slight improvement in ADL assistance requirements. A task tool associated with the most recent UAS recommended 51 hours per week to meet her personal care needs, an increase from 32 on the prior assessment.

The health plan's determination is overturned.

The requested health service/treatment of Personal Care Assistance Services 12 hour per day 7 days per week (Monday through Sunday) a total of 84 hours per week is medically necessary for this patient.

The patient has advanced dementia and is completely incontinent of urine. She cannot perform her pull up changes independently. Additional hours would not be intended for safety monitoring and security alone; they would be used to assist with personal care tasks of toileting and changing that require caregiver assistance. These needs cannot be scheduled and performed at set times. The task tool can be used as a guideline for minimum number of hours per week to address personal care needs, but this does not account for patients with frequent and unscheduled personal care needs, such as in patients with incontinence and advanced dementia.