Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease
Treatment: Home Health Care

Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease
Treatment: Home Health Care/Personal Care Worker (PCW) Service: 7 Days per Week, 24 Hours per Day - Total of 168 Hours per Week, Continuous Care by More Than One Person.

The health plan denied the requested Personal Care Worker (PCW) Service: 7 Days per Week, 24 Hours per Day - Total of 168 Hours per Week, Continuous Care by More Than One Person as not medically necessary. The health plan's determination is overturned.

The patient is a female with a past medical history of dementia, left post cerebral artery (PCA) stroke with functional quadriplegia, chronic obstructive pulmonary disease (COPD), pulmonary embolism with chronic anticoagulation, urinary incontinence, bowel incontinence, anxiety, hypertension, hyperlipidemia, hypothyroidism, and diabetes mellitus type 2 who had been assigned consumer directed personal assistance program (CDPAP) services 12 hours/day, 7 days/week, to total 84 hours/week based on an assessment. This assessed the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, phone use, and shopping while maximum assistance with tasks of managing medication, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. With task of eating, the patient was assessed at extensive assistance. The patient saw neurology via telemedicine with visit note stating the patient had history of loss of consciousness episodes for the last 4-5 years, Alzheimer's dementia since age 67 years, and a debilitating left PCA stroke at age 74 years. The visit note also stated the patient had expressive aphasia, low expressive output, and right hemiparesis. In addition, the video visit note stated the patient had a COVID-19 infection and the patient had been started on Modafinil with improvement in confusion and sleepiness. 
The patient's palliative home-based medical service provider sent a letter noting the patient's worsening of the inability to bathe and dress independently, as well as being incontinent of bowel and bladder. The provider noted the patient needed an increase in the number of hours of assistance for completion of instrumental activities of daily living (IADLs), including bathing, dressing, turning and positioning, and meal preparation and it was their opinion the patient would benefit from 24-hour care of a home attendant. 

The health plan's determination of medical necessity is overturned, in whole.

Yes. There is documentation from the patient's neurologist and primary care physician of worsening dementia, as well as recurrence of decubitus ulcers. There is documentation from the patient's primary care physician and neurologist of a need for 24-hour, split shift care. Even with the initiation of visiting nurse services for wound treatment, it would still be recommended to turn and reposition every 2 hours to promote healing. The patient is incontinent of bowel and bladder and also requires frequent changing of incontinence supplies to promote healing. The patient drinks and eats in the overnight hour and pockets food in her mouth, putting her at risk for aspiration if not assisted with eating and positioning in bed. 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/personal care worker (CDPAP/PCW) services 24 hours/day, 7 days/week, to total 168 hours/week, continuous 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.