Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Increase Personal Care Service Home Attendant Level II; Eight Hours per Day x Seven Days per Week. A Total of 56 Hours. 

The insurer denied the Increase Personal Care Service Home Attendant Level II; Eight Hours per Day x Seven Days per Week. A Total of 56 Hours. 
The denial is overturned. 

This female has multiple chronic conditions including dementia.  She lives with her husband who works during the day.  She is appealing denial of increase in personal care services (PCS), home attendant level II, eight hours per day times seven days per week, total of 56 hours. The plan approved an increase to 28 hours per week. 

Uniform Assessment System (UAS) evaluation completed showed modified independent cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with bathing; extensive assistance with managing medications, stairs, transportation, personal hygiene, lower body dressing, walking, locomotion, and toilet transfer; limited assistance with phone use and upper body dressing; and supervision with toilet use, bed mobility and eating.  She has generalized weakness, an unsteady gait and uses a walker for ambulation and a wheelchair for far distances.  Compared to Uniform Assessment System (UAS) evaluation completed previously, shows decline with meal preparation, housework, shopping, phone use, transportation, bathing, personal hygiene, dressing, walking, locomotion, and toileting. 

Statements from New York Sate note the patient was hospitalized with a subdural hematoma as result of a fall.  She was in a nursing home for approximately six months.  It notes that the patient has increased needs for personal care assistance and requires assistance with activities of daily living (ADLs) at unpredictable times throughout the day.  She requires frequent verbal prompting and cuing. 

A letter from the provider shows the patient will be discharged and needs eight hours of home care services. 

Yes, the proposed treatment is medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient has multiple chronic conditions, including dementia and generalized weakness.  She was hospitalized after a fall resulted in a traumatic brain injury.  She is appealing denial of increase in personal care services, home attendant level II, eight hours per day time seven days per week, a total of 56 hours. The plan approved increase to 28 hours per week. 

Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs), except toilet use, bed mobility and eating.  Compared to Uniform Assessment System (UAS) evaluation completed previously, shows decline with meal preparation, housework, shopping, phone use, transportation, bathing, personal hygiene, dressing, walking, locomotion, and toileting.   Appeal statements note that there has been a decline in the patient's cognitive and physical functioning since hospitalization.  There has been a significant deterioration in the patient's functioning between Uniform Assessment System (UAS) evaluation.  The patient requires a significant amount of assistance with activities of daily living (ADLs).  The approved personal care services (PCS) 28 hours per week is inadequate to meet the patient's needs for assistance with activities of daily living (ADLs) and personal care.  The proposed increase in personal care services (PCS) to total 56 hours per week is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.