Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, Generalized Weakness
Treatment: 168 hours/week, 12 hours x 2 shifts x 7 days per week; personal care aide- level 2.
The insurer denied 168 hours/week, 12 hours x 2 shifts x 7 days per week; personal care aide- level 2.
The determination is upheld.

This is a male patient with a medical history notable for dementia, coronary artery disease, peripheral vascular disease, gait disorder, and frequent urination. The patient was approved for 14 hours per day, 7 days per week (98 hours per week) of level 2 personal care services. The patient and his care team requested an increase to 24 hours per day (2-12 hour split-shift), 7 days per week (168 hours per week) and this request was partially denied by the health plan; they did approve an increase to 16 hours per day, 7 days per week (112 hours per week).

The patient's physician provided a letter of support for this appeal. The letter lists the patient's current medical diagnoses and requests to "consider increasing home care hours due to multiple medical problems and worsening of generalized weakness, dementia." There is no discussion of unmet personal care needs.

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient's cognition was moderately impaired; he was oriented to person and place only and able to answer some basic questions. (Prior Mini-Mental State Examination (MMSE) performed and score was 17/30). From a functional standpoint, he requires total dependence for meal preparation, housework, and stairs. He requires maximal assistance for medications, finances, phone use, shopping, and transportation. For his activities of daily living (ADLs), he requires maximal assistance for bathing, dressing lower body, locomotion, and toilet transfer. He requires extensive assistance for hygiene, dressing upper body, walking, and toilet use. He requires limited assistance for bed mobility and eating. He has daily episodes of urinary stress incontinence and uses pull ups. He is continent of stool. Skin is intact. He is able to walk about 25-30 feet with his cane, but usually has his daughter or aide present for physical assistance if needed. He needs physical assistance with transfers. Compared with a prior assessment, there was not a significant change in functional status. At issue is the medical necessity of 168 hours/week, 12 hours x 2 shifts x 7 days per week; personal care aide- level 2.

The requested health service of 168 hours/week, 12 hours x 2 shifts x 7 days per week; personal care aide- level 2 has not been clearly demonstrated to be medically necessary for this patient.

The patient has dementia and generalized weakness and relies on others for most personal care needs. He is approved for 16 hours per day to address these needs, but the request is to increase to 24 hours per day. As to whether or not the patient has personal care needs overnight such that he cannot be left alone for 8 hours, there is no documentation to demonstrate that he requires personal care overnight. He does not have turning and repositioning requirements. He may require supervision due to his dementia diagnosis, but supervision is not a covered service provided by level 2 personal care aides unless it is incidental to another personal care need.