Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Personal care services, 24 hours per day, 7 days a week (live in) [13x7 for a total of 91 hours a week].
The insurer denied Personal care services, 24 hours per day, 7 days a week (live in) [13x7 for a total of 91 hours a week].
The determination is overturned.

This is a patient with a past medical history of right breast cancer, hypertension, anemia, dementia, osteoarthritis, osteoporosis, right heel pressure ulcer, urinary incontinence, and coronavirus disease 2019 (COVID 19) pneumonia who had been assigned personal care assistant (PCA) services 4 hours Monday, Wednesday, Friday to total 12 hours/week prior to her COVID 19 hospitalization. The patient had been hospitalized with resultant stage 3 right posterior heel pressure wound and stage 3 sacral ulcer. The patient had an assessment tool performed over the telephone. The patient was assessed at total assistance for tasks of ordinary housework and stairs while maximal assistance with tasks of meal preparation, shopping, transportation, bathing, and dressing lower body. For tasks of managing finances, managing medication, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while assessed at limited assistance for tasks of phone use and bed mobility. The patient was assessed at supervision for task of eating. 
The Uniform Assessment System (UAS) noted the patient lives with her daughter although further in report it noted the daughter was staying with the patient due to recent hospitalization and need for care/assistance. The report also stated the patient was alert and oriented x 2, had minimal impairment of cognitive skills, needs queueing/reminder with daily tasks, functional and mental capacity has declined since hospitalization, and needs encouragement and guidance with daily tasks like medication administration, food and liquid intake encouragement, dressing, bathing and all other daily activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The universal assessment tool documentation noted the patient had stage 3 sacral ulcer and a stage 3 right heel ulcer since her COVID 19 hospitalization. The daughter reported to the assessment nurse the patient ambulates using a walker with maximum assist by others but is mostly wheeled by others. The  assessment noted the patient's daughter's to be her informal helpers for the patient. Following this assessment, the patient was assigned PCA services 8 hours/day, 7 days/week to total 56 hours/week. The patient had an office visit with her podiatrist noting the patient's recent hospitalization and right heel ulcer, that patient did not follow up with podiatrist and wound care specialist after hospitalization, that the visiting nurse service (VNS) was changing right heel dressing every other day, that the wound looks better than from discharge from hospital, and there was no malodor or drainage from the wound. The physical exam from this office visit notes the 2.3 x 3.2 centimeter (cm) wound with fibro-granular base to the posterior aspect of the right heel which probes to bone at the center of the wound with no malodor or signs of acute infection. The wound was debrided with application and prescription for Santyl/dry sterile dressing (DSD). 
The patient was also seen by her primary care physician (PCP) on the same date with office note stating she was there to establish care as a new patient, had issues with memory loss and confusion including night time wandering, and patient was independent in ADLs except receiving assistance with bathing, dressing and needs assistance with all IADLs. The note also states if the patient's daughter needs to return to Maryland the patient will need 24 hour care with care needs including bathing and dressing and all cooking, cleaning, shopping, and home care. There was a request to increase PCA services hours to 24 hours/day, live-in but the insurer provided final adverse determination letter stating the request did not meet criteria. 
The plan recommended a hospital bed to help offload right heel pressure ulcer, stated the aide is not able to always watch you, recommended splitting current hours to meet morning and evening needs, recommended patient always use walker to prevent falls, use pull ups to help keep patient dry and rely on the aide for assistance when present, and that the plan does not provide time for companionship, safety, supervision or when tasks are not being done. There was an appeal on this denial. The patient's PCP provided a letter on the same date stating there was critically needed help in the form of 7 days, 24 hour home care services and this level of care is medically necessary due to her diagnosis of dementia, urinary incontinence, open right heel ulcer, frailty, breast cancer, osteopenia of the lumbar spine, hypersomnia with sleep apnea, sensorineural hearing loss, gait dysfunction, insomnia, COVID 19 and history of sacral ulcer. The letter further states the patient needs hands on assistance when transferring from all surfaces, as her cognition, age and frailty render her a high fall risk. This letter also states the patient requires toileting during the day and overnight hours (3-4 times) and is dependent on another person to assist her with the same as she is unable to properly clean herself and dispose of soiled diapers during these episodes. The PCP further states given her history of sacral ulcer, which resolved a month ago and her current right heel ulcer, provision with assistance with toileting and repositioning overnight is imperative in order to maintain her skin integrity and promote healing of the open wound. The letter states the patient has insomnia, probably secondary to her dementia diagnosis, during these episodes she is redirected, provided with support and distractions. Finally, the letter states we are requesting 24 hour care as her needs exceed her current hours of care (7x8) and render 24 hour care medically necessary, lack of the same will be detrimental to her health and wellbeing.  At issue is the medical necessity of the requested personal care services.
The patient had a hospitalization for greater than two weeks related to COVID 19 pneumonia with subsequent reduction in her functional and mental capacity. The UAS incorrectly stated that the patient lived with her daughter when the daughter came to stay with the patient due to the patient's need for increased assistance with ADLs and IADLs (although in parts of report it stated the daughter came to stay with the patient). The UAS report also noted the patient's need for help, queueing, and reminders with daily ADL and IADL tasks. There is documentation in this assessment that the patient was mostly wheelchair bound requiring assistance to transfer and propel in wheelchair. The patient did not have informal helpers as the assessment stated as the patient's family was staying with her until she had improvement in her functional status from hospitalization or had appropriate assignment of PCA service hours to meet the patient's needs when the informal helpers were no longer available. The assessment was performed over the telephone and underestimated the patient's assistance needs for personal hygiene, walking, locomotion, transfer toilet and toilet use. The plan did not take into account the patient's unscheduled and unpredictable needs which span a 24 hour time frame, thereby improperly relying on a task based assessment tool. The patient has unscheduled and unpredictable care needs with toileting, transfer toilet, incontinence cares, walking, and locomotion. The patient does have dementia with insomnia but PCA service hours are not solely for safety and supervision but to assist the patient with ADLs and IADLs. The patient requires safety monitoring, supervision and cognitive prompting to assure safe completion of one or more ADLs and IADL's. The patient has a history of sacral ulcer and current right heel ulcer requiring assistance with toileting needs, incontinence cares, transferring, and locomotion. 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 patient's PCP provided documentation of medical necessity of increase in PCA services hours.