Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder/Other/Lewy Body Dementia
Treatment: Home Health Care/Personal Care Aide Services of 7 days per week, live-in.
The health plan denied the requested Personal Care Aide Services of 7 days per week, live-in. 
The health plan's determination is upheld.

This is a case review for a male with a medical history notable for Lewy Body Dementia. The patient was previously approved for 24 hour live-in personal care aide services, 7 days per week. On review, the health plan reduced the patient's hours to 6 hours per day, 7 days per week (42 hours per week). The reduction from live-in level personal care services is the subject under review.
An office visit note from the patient's neurologistwas provided. The note states that the patient has Lewy Body Dementia and has "difficulties with his basic daily activities and it is recommended that he continue with this level of care [live-in aide]." The note also states that alternative family living arrangements are not feasible.
The patient is working with physical therapy to provide additional strength and conditioning to help with performing activities of daily living. A note from the patient's assessment was provided for review.
A "daily schedule" for the patient was provided for review. This was not an actual log of events, but a guideline for a typical day. It describes hygiene, showering, meal preparation, and medication administration. It also describes non-personal care functions such as "engage client in any activity that keeps him from hallucinations and illusions during mornings" and "constant supervision." It also makes note that there are some nights where the client "wakes up from illusions and hallucinations, trying to defend himself from people, trying to get any tool he finds around. Sometimes, banging doors at night, hitting items with tools and trying to fight."
A Uniform Assessment System (UAS) was most recently completed and was available for review. The patient's cognition was found to be moderately impaired. His recall was zero of three at five minutes. He was noted to be easily distracted and easily agitated. By report, he wanders at night, and gets angry and agitated easily. He "plays with his stool when he goes to the bathroom, he can be resistant to changing clothes and showering." From a functional standpoint, he requires total dependence for meal preparation, housework, and shopping. He requires maximal assistance for medications and phone use. For his activities of daily living (ADLs), he requires extensive assistance for toilet use. He requires limited assistance for dressing. He requires supervision only for other ADL's. He is continent of urine and stool. Skin is intact. Compared with a prior UAS, the patient showed a decline in cognitive and functional status. A task tool associated with the most recent assessment recommended 34.24 hours per week to address his personal care needs.
At issue is the medical necessity for the requested Personal Care Aide Services of 7 days per week, live-in.

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

The requested health service/treatment of Personal Care Aide Services of 7 days per week, live-in has not been demonstrated to be medically necessary for this patient.
The patient has functional needs that primarily revolve around instrumental activities of daily living (IADLs). He is able to perform most ADL's. His cognition is declining due to Lewy Body Dementia. Personal Care Aide Services cannot be approved for safety monitoring and supervision only in the absence of the need for a level 1 or level 2 personal care function. Because he is independent in many activities, he does not qualify for live-in services. 42 hours per week should address his needs, based on the UAS assessment. Additional hours would be to provide safety monitoring and supervision which is not covered.