Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polyarthritis, Dementia
Treatment: Personal Care Aide (PCA) Level 2: 8 hours/day, 7 days/week, a total of 56 hours/week
The insurer denied the request for PCA level 2: 8 hours/day, 7 days/week, a total of 56 hours/week.
The health plan's determination is overturned.

The patient is a female with a medical history notable for arthritis and dementia. The patient was approved for 4.5 hours/day, 5 days/week (22.5 hours/week) of level 2 personal care services. The patient and her care team requested an increase to 8 hours/day, 7 days/week (56 hours/week) and this request was partially denied by the health plan; they did approve an increase to 31.5 hours/week.

Additional hours were requested because the patient's health condition has been deteriorating recently, both from a cognitive and functional standpoint. They are requesting additional assistance for housekeeping, meals, and for escorts to doctor appointments. An advocacy letter states that the patient has experienced falls. Since the falls, the patient has had a further functional decline and can no longer ambulate alone with a cane. She now requires assistance with toileting, hygiene, bathing, and dressing. She does not have any informal care to help with her unscheduled personal care needs throughout the day.

The patient's physician provided a letter of support for this appeal. The letter states that the patient is homebound and lives alone. She requires assistance for most activities of daily living (ADLs) and has declined from both a functional and cognitive standpoint. Therefore, the physician requests additional home health aide hours be granted to the patient.

Medical records were provided and reviewed in detail. They describe recent falls and functional limitations of the patient. The caregiver logs were also provided for review, which describe multiple unscheduled personal care needs.

A Uniform Assessment System (UAS) was completed via teleconference and the patient's daughter was present. The patient lives alone in an apartment. She was alert and oriented to person and place only. Her recall was 1 out of 3 at five minutes and she is unable to perform procedural tasks such as handwashing without cueing. For her instrumental activities of daily living (IADLs), she required total dependence for housework. She required maximal assistance for meal preparation and shopping. She required extensive assistance for finances, transportation, and stairs. She required extensive assistance for all ADLs (with the exception of eating, for which she was independent). She is occasionally incontinent of urine and uses liners for incontinence care. Compared to a prior UAS, she showed a decline across multiple domains. A task tool associated with the most recent assessment recommended 5.5 hours/day, 5 days/week to address her personal care needs; this was an increase of 1 hour/day when compared to her prior assessment.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The requested health service of personal care aide level 2: 8 hours/day, 7 days/week for a total of 56 hours/week is medically necessary for this patient. The records provided demonstrate that the patient has had a cognitive and functional decline over the past year. She requires hands-on assistance with essentially all IADLs and ADLs, and by definition, many of these will be unscheduled. She has no informal support at home. Her 3 falls last year while attempting to perform personal care tasks independently are evidence that her personal care needs are not currently being met. Additional hours are medically necessary to address her personal care needs, not simply for safety monitoring and security.

The health plan's determination of medical necessity is overturned in whole.