Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular
Home Health Services

Diagnosis: Alzheimer's dementia
Treatment: Home care/personal care HHC (Home Health Care)- personal care aide- live-in per diem increase to 24 hours per day split-shift 
The insurer denied home care/personal care HHC- personal care aide- live-in per diem increase to 24 hours per day split-shift. 
The determination is overturned.

This is a female patient with a past medical history of Alzheimer's dementia, chronic obstructive pulmonary disease (COPD), history of deep vein thrombosis (DVT), chronic anticoagulation, glaucoma, hypertension, vertigo, osteoarthritis, congestive heart failure, obesity, urinary incontinence, and fecal incontinence who had personal care assistant (PCA) services based on an assessment. The patient was hospitalized with a Clostridium (C) difficile infection. The hospital notes at that time stated the patient had PCA services 24 hours/day, 7 days/week, live in. The patient subsequently had emergency room visits due to pressure wounds. There was a request to increase PCA services and the patient underwent another assessment.
Notes from the assessment stated the patient had severely impaired cognitive skills and noted "no pressure ulcer". The patient was in the emergency room again with a pressure ulcer. The patient's primary care provider sent a letter to request personal care services for the patient as medically necessary to meet all of her personal care needs. The provider noted the patient was homebound, bedbound, required a wheelchair to ambulate, and required a Hoyer lift to be transferred. In addition, the provider stated it was medically necessary for the patient to receive 24 hours, split shift personal care services to total 168 hours/week. The provider also noted the patient was bedbound/wheelchair-bound due to her medical conditions and was incontinent of bladder and bowel and had a history of pressure ulcers and must be turned every 2 hours throughout the day and night. The provider also recommended the changing of pull-ups and perineal care performed regularly throughout the day and night to prevent UTIs (urinary tract infection) and skin breakdown. At issue is the medical necessity of
home care/personal care HHC- personal care aide- live-in per diem increase to 24 hours per day split-shift.

The services are medically necessary. There is documentation from the patient's medical provider of medical necessity of increased PCA services to 24 hours, split shift, 7 days/week. The provider specifically documented the medical necessity of turning and repositioning every 2 hours to treat and prevent pressure wounds. There is documentation that the patient has current pressure wounds and the universal assessment incorrectly noted the patient did not have any pressure wounds. The patient's care needs in the overnight hours would not allow a PCA at least 5 hours of uninterrupted sleep. 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 (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, 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 his own home.