Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 96 hours per week
The insurer denied Home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 96 hours per week.
The determination is overturned.

The patient has a past medical history of Alzheimer's dementia, diabetes mellitus type 2, hypertension, gastroesophageal reflux disease (GERD), osteoarthritis, hyperlipidemia, obesity, glaucoma, asthma, anxiety, depression, urinary incontinence, and bowel incontinence who had been assigned personal care assistant (PCA) services 84 hours/week based on assessment performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, and toilet use. With the tasks of walking, locomotion, and transfer toilet the patient was assessed at extensive assistance while limited assistance with tasks of bed mobility and eating.

There was a request to increase PCA services and the patient underwent another assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, dressing lower body, and toilet use while maximum assistance with tasks of managing medication, phone use, bathing, personal hygiene, dressing upper body, locomotion, and bed mobility. The patient was assessed at limited assistance with task of eating. Notes from the assessment stated the patient was nonambulatory and had to be transferred via a Hoyer lift. The insurer sent an initial adverse determination denial notice denying request to increase PCA services stating the assessment showed no change in activities of daily living (ADLs) within the last 90 days and no change in the patient's overall self-sufficiency. In addition, the denial stated there had been no change in social circumstances and the patient had support of her family. The insurer sent a final adverse determination denial notice denying the request to increase PCA services stating based on the appeal review, the patient was reassessed and the authorized hours were adjusted accordingly. The denial also stated hours beyond those currently authorized would be for safety monitoring which is not a covered benefit. The patient's PCP (primary care physician or provider) appealed the denial decision.

At issue is the medical necessity of home care/personal care (HHC) - level 2 personal care services, per 15 minutes increase to 96 hours.

The services are medically necessary. The patient's medical provider appealed the denial decision. The patient has 24-hour care needs and therefore a task-based assessment should not have been utilized to calculate PCA services. The plans on the assessments showed an increase in assistance needs with multiple tasks including stairs, transportation, dressing lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The patient requires assistance at all times outside of informal help. The requested increase in PCA services is not solely for safety and supervision, but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). 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, Consumer Directed Personal Assistance Program (CDPAP)/PCA services 96 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.