Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase in Personal Care Worker (PCW) Services to 4 days per week, 20.5 hours per day (Monday through Thursday) and 2 days per week, 19 hours per day (Friday and Saturday) and 1 day per week, 9 hours per day (Sunday) provided by more than 1 person; 129 per week.
The insurer denied the request for increase in Personal Care Worker (PCW) Services to 4 days per week, 20.5 hours per day (Monday through Thursday) and 2 days per week, 19 hours per day (Friday and Saturday) and 1 day per week, 9 hours per day (Sunday) provided by more than 1 person; 129 per week.
The health plan's determination is overturned.

The patient is a female with a medical history that is notable for dementia. The patient and her care team requested an increase in Personal care worker services from 4 days per week, 19 hours per day (Monday through Thursday) and 2 days per week, 10 hours per day (Friday and Saturday) and 1 day per week, 9 hours per day (Sunday) provided by more than 1 person; 105 hours per week, to 4 days per week, 20.5 hours per day (Monday through Thursday) and 2 days per week, 19 hours per day (Friday and Saturday) and 1 day per week, 9 hours per day (Sunday) provided by more than 1 person; 129 per week. The request was partially approved by the health plan, who did approve in increase to 111 hours per week (19 hours per day 4 days per week, live-in 2 days per week, and 9 hours per day 1 day per week).
The patient's family and advocacy team provided a letter of support for this appeal. The letter outlines the reasons why additional hours are needed. The patient essentially requires continuous care when informal support is not available. They assert that some of the determinations on the Uniform Assessment System (UAS) and final adverse determination notice underestimate the patient's true level of need.
Hospital records report that the patient had a kyphoplasty procedure for lumbar fracture. 
A Uniform Assessment System (UAS) was most recently conducted was available for review. The assessment was conducted in person. The patient's cognition was noted to be severely impaired, with no change from prior (although this was disputed elsewhere in the documentation). For the patient's Instrumental activities of daily living (IADL), she requires total dependence for meal preparation, housework, finances, phone use, stairs, transportation, and shopping. She requires maximal assistance for medications. For her activities of daily living, the patient requires maximal assistance for bathing, dressing, and toilet use. She requires extensive assistance for all other activities of daily living. She is frequently incontinent of both urine and stool. Compared to a prior assessment, the assessment did not describe a significant change in the patient's cognitive or functional status.
 
The patient requires extensive or maximal assistance for all activities of daily living. She is totally dependent on others for assistance with instrumental activities of daily living. She has advanced dementia and cannot direct her own care. She has incontinence of both bowel and bladder. The patient will essentially require continuous 24-hour care, given that her personal care needs are expected to be continuous and unscheduled throughout both the day and night. She does have some informal support which will help, but during times when reliable informal support is not available the patient will need continuous personal care services. The increase in hours is therefore medically necessary and reasonable to prevent any gaps in care for the patient. Failure to provide for her personal care needs could result in the patient attempting personal care activities on her own, which could lead to injuries such as repeated fractures. Additionally, given her incontinence, she requires prompt addressing of any incontinence episodes to prevent skin breakdown and/or infection.