Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease, Fall Risk
Treatment: Home care/personal care, home health care (HHC)- level 2 personal care services, per 15 minutes increase to 84 hours per week
The insurer denied the home care/personal care, home health care (HHC)- level 2 personal care services, per 15 minutes increase to 84 hours per week.
The health plan's determination is overturned.

The patient is a female with a medical history notable for Alzheimer's dementia and incontinence. The patient was approved for 56 hours per week of personal care services. The patient and her care team requested an increase to 84 hours per week, and this request was partially declined by the health plan; they did approve an increase to 70 hours per week. The denial of 84 hours per week is the subject under review.

A letter of support for this appeal was provided by the patient's nurse practitioner. The letter states that the patient was recently hospitalized with Coronavirus (COVID) and acute renal failure and has had a subsequent functional decline. She is now unable to walk without assistance and is confined to a bed or wheelchair. She has urinary and fecal incontinence and requires multiple daily and nighttime changes of her diapers. For these reasons, the provider feels it is medically necessary to increase her hours.

A community advocate provided a letter of support for this appeal. The letter expresses concern that the patient is left alone in a soiled diaper for 14 hours per day between personal care aide shifts. She is unable to do toileting, medications, or other personal care tasks for an extended time each day.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week is medically necessary for this patient. A Uniform Assessment System (UAS) was completed was available for review. The assessment was completed via teleconference. The patient lives alone. Her cognition is moderately impaired; the patient was oriented to self only and she cannot direct her own care. For her instrumental activities of daily living (IADL's), she requires total dependence for meal preparation, housework, finances, stairs, shopping, and transportation. She requires maximal assistance for medications. For her activities of daily living (ADL's), she requires total dependence for locomotion and toilet use. She requires maximal assistance for bathing, hygiene, dressing, and bed mobility. She requires extensive assistance for eating. She is frequently incontinent of urine and stool.

The patient relies completely on others for her personal care needs. She cannot transfer or manage toileting/diaper changes on her own. It is clearly established that it is medically necessary to provide for these personal care needs. Her functional needs are expected to be continuous and unscheduled, and thus she cannot be expected to perform them all during a shorter personal care aide shift each day.

The health plan's determination of medical necessity is overturned in whole.