Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia. 
Treatment: Home Care / Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 Minutes Increase to 84 Hours per Week. 
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 84 Hours per Week. 
The determination is overturned. 

This is a female patient with a medical history notable for Alzheimer's dementia, epilepsy, and difficulty walking. The patient is approved for 6 hours per day, 7 days per week (42 hours per week) of level 2 personal care services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan. 
The patient's physician provided a letter of support for this appeal. The letter states that the patient's physical and mental status has declined significantly since the beginning of the year. The physician feels that an increase in home care services is necessary to meet the patient's needs. 
The patient's neurologist provided a letter of support. The letter states that the patient requires a 4-wheel walker for ambulation and has chronic dizziness. Has has had multiple falls recently which have required inpatient rehabilitation. The neurologist requests additional hours to cover the patient during the time she is awake. 
The patient's healthcare proxy provided a letter of support for this appeal. The letter writer was present for the assessment. The writer expressed concern over the patient's leg wounds and her inability to care for herself for 18 hours per day in her current condition. 
A Uniform Assessment System (UAS) was completed and was available for review. She is frequently incontinent of urine and continent of stool. She uses pullups for incontinence care. The assessment states she has had no falls in the last 90 days. She has bilateral lower extremity ulcers secondary to venous stasis. A task tool associated with the assessment recommended 40.25 hours per week to address her personal care needs. Compared to a prior assessment, the patient showed a decline in cognitive and functional status. At issue is the medical necessity of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 84 Hours per Week.

The requested health service of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 84 Hours per Week is medically necessary for this patient.
The patient has shown a substantial decline in cognitive and functional status in the first half of this year, as evidenced by the UAS and detailed in the physician letters. She is reliant on others for assistance with essentially all activities of daily living. She cannot toilet independently and has frequent incontinence. Her care needs are expected to be continuous and unscheduled throughout the day. Her neurologist's assertion that she should have additional hours to cover her throughout the day is medically necessary and reasonable as she cannot be expected to do all of her personal care tasks (such as toileting) in a single six-hour window each day. There is concern that the UAS may actually underestimate her true level of need. Her falls (as documented by her neurologist) are evidence of unmet personal care needs. Therefore, the requested increase to 84 hours per week is medically necessary for the patient.