Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-Other- severe dementia
Treatment: The increase of Personal Care Aid services to 72 hours per week 
The health plan denied the increase of Personal Care Aid services to 72 hours per week as not medically necessary. The reviewer has overturned in whole the health plan's determination.

This is a patient with medical history notable for severe dementia, incontinence, cirrhosis, and arthritis. 
The patient's physician provided a letter of support for this appeal. The letter states that the patient has been declining over the last several months. She is being treated for liver cirrhosis which is advanced. On a recent examination, she was alert and oriented to place and person only. Due to the patient's rapid decline, the patient's family has been struggling to provide adequate care. The physician states that the requested increase in hours is medically necessary to treat the patient's condition.
A Uniform Assessment System (UAS) was completed. The assessment was conducted in person. The patient lives with her son in an apartment. Cognition was described as alert and oriented times three. The patient was self-directing but forgetful at times. For her instrumental activities of daily living, the patient requires total dependence for housework. She requires maximal assistance for shopping, stairs, and meal preparation. She requires extensive assistance for finances, medications, and transportation. For her activities of daily living, the patient requires extensive assistance for bathing and dressing lower body. She requires limited assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. She is independent for bed mobility. She is infrequently incontinent of urine and continent of stool. There was one fall in the previous 30 days. There was no pressure ulcer present.  Compared to a prior assessment the patient showed a functional decline.
Office visit notes were provided for review. The provider stated that the patient was admitted to the hospital over the summer for sepsis with resulting short-term rehabilitation. Since that time, the family has been struggling to meet her personal care needs. A mini mental state examination performed at that visit score was 11 out of 30, consistent with severe cognitive impairment. The provider recommended increased personal care hours to meet her needs.
An office visit with the patient's primary care physician was available for review. The patient's cognition has been severely declining. She was not alert or oriented. She is awaiting a liver transplant. The primary care physician also agrees that additional home care hours are medically necessary for the patient.

The requested service of Home Care / Personal Care Level 2 Personal Care Services Increase to 72 Hours per Week service is medically necessary for this patient.
The patient has end-stage delivered disease with cirrhosis. Her cognitive and functional status is rapidly declining. This is not unusual in patients who are suffering from end-stage liver disease. The assessment stated that the patient was alert and oriented, yet the office visit notes describe severe cognitive impairment. Her cognitive and functional status is also likely waxing and waning, which is typically seen in end stage liver disease. Multiple medical provider notes attested to the patient's personal care needs not being adequately covered at her current allotment of personal care hours. This is not surprising as she is likely experiencing a dramatic functional decline over the past 6 months due to her worsening liver disease. The requested increase in home care hours is therefore medically necessary and reasonable for the patient. Failure to provide for the patient's personal care needs could result in additional falls and/or injury.