Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Personal care assistant.
The insurer denied Personal Care Services: 12 Hours per Day, 7 Days per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of vascular dementia, coronary artery disease, urinary incontinence, hypertension, gastroesophageal reflux disease (GERD), glaucoma, osteoporosis, colon cancer, hearing loss, osteoarthritis, and low back pain who had been approved PCA (personal care assistant) services. There was a request to increase PCA services and the patient underwent a telehealth assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and phone use while maximum assistance with tasks of managing finances, managing medication, stairs, shopping, transportation, bathing, dressing lower body, and toilet use. With tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and eating the patient was assessed at extensive assistance while limited assistance with task of bed mobility. Notes from the assessment stated the patient's and NFLOC (nursing facility level of care) score went from 21 to 26, the patient had moderate of cognitive impairment, the patient had no informal help, the patient did not know what to do when a meal was presented to her, and the patient used a walker indoors with assistance.

Personal Care Services: 12 Hours per Day, 7 Days per Week is medically necessary for this patient.
There is documentation of worsening cognitive and physical functioning following COVID-19 infection with noted increased assistance needs with activities of daily living (ADL) and Instrumental activities of daily living (IADL) when comparing recent assessments. The patient had increased assistance needs with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, toilet use, bed mobility, and eating. The patient's NFLOC (nursing facility level of care) score went from 21 to 26. It was noted the patient did not have informal help. The patient requires at least extensive assistance with tasks of walking, locomotion, transfer toilet and toilet use. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to address a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The plan assumed the patient had informal help outside of the current PCA hours. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.