Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Home Care / Personal Care (HHC - Level 2 Personal 
Care Services, per 15 minutes) Increase to 84 Hour(s) per Week
The insurer denied Home Care / Personal Care (HHC - Level 2 Personal 
Care Services, per 15 minutes) Increase to 84 Hour(s) per Week. 
The health plan's determination is overturned.

The patient is a female with a past medical history of dementia, osteoporosis, hypertension, constipation, cervical cancer, macular degeneration, hearing loss, bowel incontinence, and bladder incontinence who had been assigned personal care assistant (PCA) services for 56 hours/week based on the assessment performed via teleconference. This assessment assessed the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, stairs, shopping, transportation, equipment management, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use while maximum assistance was needed with the task of bed mobility. With the task of eating, the patient was assessed at extensive assistance.
Notes from the assessment stated the patient lived with her husband, had moderately impaired cognitive skills for decision making, could not describe an emergency plan, was bedbound following a major fall with vertebral fracture, had position change every 2-3 hours to prevent skin breakdown, must be fed by caregiver, and required a pureed diet with thickened liquids. There was a request to increase PCA services and the patient underwent an assessment assessing the patient at total assistance with all tasks. Notes from the assessment stated the patient continued to live with her spouse, cognitive skills were moderately impaired, the patient remained bedbound, activities of daily living (ADL) status compared to 90 days ago had declined, was turned and positioned every 2 hours as the patient was unable to turn herself in bed and was fed by a caregiver.

Home Care / Personal Care (HHC - Level 2 Personal Care Services, per 15 minutes) with an increase to 84 hour(s) per week is medically necessary. There is documentation from the patient's medical provider of medical necessity of the need for increased PCA services. There is documentation that the patient requires total assistance with all ADL's and Instrumental activities of daily living (IADL). The patient has 24-hour care needs and therefore a task based tool should not have been utilized to determine PCA service hours. The patient has unpredictable and unscheduled care needs and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs.
There is documentation in the plans own assessments that the patient is turned and repositioned every 2 hours to prevent bedsores and skin breakdown. There is documentation that the husband is no longer able to provide the same level of informal support due to his own medical issues. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADL's and IADL's. 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 84 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.
 
The health plan's determination of medical necessity is overturned in whole.