Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: personal care assistance services, 12 hours per day, 7 days per week (Monday through Sunday), for a total of 84 hours per week.
The insurer denied personal care assistance services, 12 hours per day, 7 days per week (Monday through Sunday), for a total of 84 hours per week.
The determination is overturned.

The patient has a history of dementia, ischemic stroke, heart failure with preserved ejection fraction, insulin-dependent type 2 diabetes, hypertension, chronic kidney disease, peripheral artery disease, carotid stenosis, benign prostatic hyperplasia (BPH), arthritis, and diabetic neuropathy. He is currently receiving 6 hours per day, 7 days per week of level 2 personal care services. The patient and his physician have requested an increase in his home care services to 12 hours per day, 7 days per week (total 84 hours per week). This request was denied by the health plan and is the subject of this appeal.
Support for this appeal is provided by a comprehensive letter from the treating primary care physician. The physician notes that it is their medical opinion that the patient needs a significant increase in home services due to a multitude of reasons. The patient lives at home with his wife, but she is unable to provide assistance due to her own medical issues. There has been progressive dementia which has caused worsening issues with attention and executive functioning. He had several embolic strokes from his carotid stenosis last year which have contributed to accelerating his dementia as well as affecting his gait. His diabetes has led to peripheral neuropathy which has also affected his gait. He is able to use the toilet on his own, but the combination of arthritis and balance issues have led to difficulty with moving from a sitting to standing position and using the bathroom at the end of his hallway. This problem is compounded by his BPH and diuretic use for heart failure which leads to frequent daytime trips to the bathroom. The physician notes he also is unable to dress himself, prepare his own meals, and manage his own insulin. This leads to a particularly "dangerous - even life threatening - situation" where the patient can have uncontrolled high or low blood sugars if his eating and insulin balance are disrupted.
The most recent office visit note from the treating primary care physician was reviewed. The notes state that he takes insulin when "he feels necessary." His wife reports a symptomatic hypoglycemic episode but the patient himself does not remember. His medication lists include both long acting and short acting insulin, both of which are administered more than once daily.
A Mini-Mental State Examination (MMSE) was performed with a score of 15/27 with a refusal to attempt shape drawing. This score is consistent with severe cognitive impairment, although he is noted to have not completed formal education which can falsely lower the score.
A Uniform Assessment System (UAS) was performed and was available for review. The patient was noted to have the review requested due to a decline in functional status and an increase in dizziness. He was alert and oriented to person and place only. He noted forgetfulness with medications. From a functional standpoint, the patient requires maximal assistance for meal preparation and ordinary housework. He requires extensive assistance for managing medications and finances. Maximal assistance is required for transportation and shopping. Extensive assistance is required for nearly all activities of daily living, including bathing, hygiene, dressing upper and lower body, walking, locomotion, and toilet transfer. Limited assistance is required for toilet use. He is independent with bed mobility. He is infrequently incontinent of urine but does not use pull-ups. He is continent of stool.
At issue is the medical necessity of personal care assistance services, 12 hours per day, 7 days per week (Monday through Sunday), for a total of 84 hours per week.

The requested health service/treatment of personal care assistance services, 12 hours per day, 7 days per week (Monday through Sunday), for a total of 84 hours per week is medically necessary for this patient. The patient's treating primary care physician presented information which support this determination of medical necessity. The patient has a diabetic medication regimen which requires multiple daily doses of insulin. He is unable to handle his medications independently (or prepare his own meals), and without proper supervision and assistance, he is at high risk for an adverse medical event such as severe hypo- or hyperglycemia which could result in hospitalization or other severe negative outcomes. His worsening dementia due to recent strokes has exacerbated this situation, both from a cognitive and functional standpoint.
Toileting is another area of concern for this patient. He can toilet independently, but cannot get up himself to transfer to the toilet any longer. Given his BPH and diuretic use for heart failure, he is likely to require many transfers throughout the day. Additionally, he has occasional incontinence issues. He is unable to dress himself (lower body) and incontinence might naturally worsen over time if he is not able to get to the bathroom with the appropriate frequency.
Given his current cognitive and functional status, it is not reasonable to expect the patient care assistant to complete all of the assistance tasks in a single six hour time period per day. The meal preparation, medication management, and unscheduled toileting needs would all preclude a single shorter time period. Therefore, the requested personal care assistance services, 12 hours per day, 7 days per week (Monday through Sunday), for a total of 84 hours per week is medically necessary.