Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Services (7 hours a day, 7 days a week)
The health plan denied: Personal Care Services (7 hiyrs a day, 7 days a week)
The determination is: Overturned

The patient is a female with medical history notable for dementia, incontinence, and gait dysfunction. The patient is approved for 7 hours per day, 1 day per week, 6.5 hours per day, 4 days per week, and 3 hours per day, 2 days per week for a total of 39 hours per week. The patient and her care team requested an increase to 7 hours per day, 7 days per week (total 49 hours per week), and this request was denied by the health plan. This denial is the subject under review.

The patient's physician provided a letter of support for this appeal. The letter states that the patient is homebound and requires assistance with activities of daily living (ADL). She lives alone and needs support for her personal care needs.

The patient's son provided a letter of support for this appeal. The letter states that the patient does not have consistent informal support due to not having any family living in the area. The letter argues that the patient needs additional hours on the weekends, as her needs for assistance with ADL's are just as great on the weekends as they are on the weekdays. He states that her current hours are insufficient to meet her needs for things like toileting on the weekends; he states that her lack of care on the weekends is the primary concern in the appeal. Furthermore, he notes that the plan attributes a large amount of informal support to the patient which is not possible given that her family lives far away.

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference with the patient's son present. The patient lives alone in an apartment. She was alert and oriented to person and place only. Her procedural and situational memory was intact, and she is able to call for help in an emergency. For her instrumental activities of daily living (IADL), she requires maximal assistance for meal preparation, housework, stairs, shopping, and transportation. She requires extensive assistance for finances and medications. For her ADL's, she requires extensive assistance for bathing, dressing her lower body, walking, locomotion, toilet transfer, and toilet use. She requires limited assistance for hygiene, dressing her upper body, and bed mobility. She is occasionally incontinent of urine and continent of stool. She uses pull-ups for incontinence care. Compared to a prior assessment, she showed a decline in function across multiple ADL's. A task tool associated with the assessment recommended 39.5 hours per week to address her personal care needs.

At issue is the medical necessity of Personal Care Services (7 hours a day, 7 days a week). The health plan's determination of medical necessity is overturned in whole. The requested health service/treatment of Personal Care Services (7 hours a day, 7 days a week) is medically necessary for this patient.

The patient requires extensive assistance with most ADL's including toileting. She currently has very little support from personal care services on the weekends, only 3 hours per day. The task tool can serve as an approximation for the needs of a patient, but the context of the patient's needs supersedes any recommendation from the plan. The patient does not have consistent informal support for the hours she is without an aide. It is therefore medically necessary for her to have personal care services for 7 hours per day every day of the week to meet her personal care needs.