Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Falls, anxiety, depression, schizophrenia, diabetes mellitus, dementia, hypertension, osteoarthritis, wandering, and urinary incontinence.

Treatment: 56 hours per week; 8 hours x 7 days; personal care aide level 2.

The insurer denied coverage for 56 hours per week; 8 hours x 7 days; personal care aide level 2.

The denial is overturned.

This is an adult patient with an extensive medical history inclusive of recurrent falls, anxiety, depression, schizophrenia, diabetes mellitus, dementia, hypertension, osteoarthritis, wandering, and urinary incontinence. The patient lives alone. The patient requires maximal assistance for housework, meal preparation, taking medications, bathing and dressing. The patient has difficulty staying on task. The patient is getting 35 hours weekly and the request is for 56 hours weekly.

The healthcare plan did not act reasonably and with sound medical judgement or in the best interest of the patient. The patient has dementia, a history of falls, urinary incontinence, wandering behaviors, difficulty with bathing, dressing, and taking medications. The patient needs help with changing diapers, assistance with morning and evening medications. Five hours in a day, does not cover these needs. The eight hours would cover the patient's needs including the management of evening medications and would ensure that the patient does not have any skin issues related to incontinence.      

56 hours per week; 8 hours x 7 days; personal care aide level 2 is considered medically necessary for this patient.

According to D'Cruz et al, 2022, in addition to disparities faced by home health aides, older adults also experience difficulty in accessing Home and Community Based Services, with disparities found along racial and rural lines. Furthermore, even when able to access these services, outcomes reflect persistent health disparities. Older adults who self-fund home support are more likely to go into debt, struggle to pay bills, fail to procure adequate food and medicine, and be more likely to become long-term nursing home residents. Certain health and social conditions, such as a diagnosis of dementia, and being a dual eligible beneficiary, further increase risk of eventual nursing home residency and of increased out of pocket expenses. Without a strong community support system, we can expect inadequately supported older adults to continue to cycle through illness, repeated unnecessary hospitalizations, and potentially unwanted nursing home admissions.

According to Reckrey et al, 2019, in the course of their day-to-day activities, paid caregivers went beyond assisting with activities of daily living by attending to patients' acute medical problems, assisting them with management of their chronic diseases, promoting their general health, and fostering mental health. Paid caregivers, patients, and proxies saw these health-related tasks as core features of the services they provided or received. Moreover, these findings suggest directions in which the paid caregiver workforce may be further developed to achieve better patient outcomes, allow more patients to remain in the community for longer periods of time, and realize greater value for Medicaid dollars spent on long-term care.
Discharge with home health care was associated with significant reduction in healthcare utilization and decreased hazard of readmission and death (Xiao et al., 2018).

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 56 hours per week; 8 hours x 7 days; personal care aide level 2 is substantiated.