Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: increase in personal care services from 55 hrs per week to 24 hrs per day (live-in)
The insurer denied increase in personal care services from 55 hrs per week to 24 hrs per day (live-in).
The determination is overturned.

This is a female patient with a past medical history of dementia, colon cancer, anxiety, depression, urinary incontinence, hyperlipidemia, hypothyroidism, hypertension, gastroesophageal reflux disease (GERD), osteoarthritis, and autoimmune disorder who had been assigned personal care assistant (PCA) services 55 hours/week based on a video assessment. There was a request to increase PCA services and the patient underwent another assessment via video assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, phone use, and shopping while maximum assistance with tasks of managing medication, stairs, transportation, bathing, and dressing lower body. With the tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and eating the patient was assessed at extensive assistance while limited assistance with task of bed mobility. Notes from the assessment stated the patient was receiving 55 hours of PCA services and private pay 36 hours/week. The notes also stated the patient's cognitive skills were severely impaired.
The insurer sent a final adverse determination denial notice continuing to deny request to increase PCA services stating the patient had no loss of motor function, it was not medically necessary to increase services to 24-hour, live-in, and based on the appeal review, the patient was reassessed, and the authorized hours were adjusted accordingly. The patient had a home visit with the primary care physician with the office notes stating the patient had taken 2-1/2 days of her pills in 1 day in the past. At issue is the medical necessity of an increase in personal care services from 55 hours (hrs) per week to 24 hrs per day (live-in).
The services are medically necessary. The patient has documented assistance needs with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time. The patient has 24-hour care needs and therefore a task based tool should not have been utilized in assigning PCA hours. The patient would require assistance outside of the currently assigned PCA services due to her unpredictable and unscheduled care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The requested increase in PCA services cannot be met solely with adaptive equipment and medical supplies. 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 24 hours/day, live-in, 7 days/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.