Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia. 
Treatment: Personal Assistance Services. 

The insurer denied Consumer Self-Directed Personal Assistance Services: 24 Hours a Day, 7 Days a Week (Split-Shift). 
The health plan's determination is overturned. 

The patient is a female with past medical history of colonic mass, pancreatic mass, hiatal hernia, Alzheimer's dementia, hiatal hernia, gastroesophageal reflux disease (GERD), chronic kidney disease, hypertension, urinary incontinence, osteoporosis, depression, and aspiration pneumonia who had Consumer Self-Directed Personal Assistance Services 11 hours/day, 7 days/week, to total 77 hour/week. The patient had fall with left hip fracture and was hospitalized and transferred to rehabilitation facility but re-hospitalized with colitis, failure to thrive, aspiration pneumonia, and colitis. Physical therapy (PT) notes from the hospital noted the patient was to be discharged to prior living arrangement with 24 hour services. Discharge planning included a request to increase personal assistance services and the patient underwent telephonic assessment assessing the patient at total assistance with tasks of ordinary housework and managing finances while maximum assistance with tasks of meal preparation, managing medication, phone use, stairs, shopping, transportation, bathing, dressing lower body, and toilet use. The patient was assessed at extensive assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, and transfer toilet while limited assistance with tasks of bed mobility and eating. 

Consumer Self-Directed Personal Assistance Services: 24 Hours a Day, 7 Days a Week (Split-Shift) is medically necessary for this patient. 

The patient has documented progressive chronic medical conditions of dementia and osteoarthritis with recent decline in physical and mental functioning following fall with hip fracture and subsequent hospitalization for sepsis. The patient's recent assessment over the telephone underestimated her assistance needs with personal hygiene, walking, locomotion, transfer toilet, and bed mobility. The patient requires sitting upright after eating to prevent aspiration and requires special diet to prevent aspiration and she requires assistance with these tasks. The patient is not able to independently ambulate or toilet nor provide her own incontinence cares. The patient's daughter is no longer able to provide informal help as she needs to return to work. The patient has unscheduled and unpredictable care needs that span a continuum of time. The insurer failed to document a plant to meet these unscheduled and unpredictable care needs. The patient's provider recommended toileting routine every 2 hours to prevent infections and skin breakdown as the patient is unable to communicate the need to use the bathroom. The increase in personal assistance services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) / Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with medical equipment and supplies. 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, Consumer Self-Directed Personal Assistance Services: 24 Hours a Day, 7 Days a Week (Split-Shift) 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.