Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-Alzheimers
Treatment: Home Health Care
The health plan denied the increase in personal care assistant service (PCAS) hours to 24Hour per day split shift as not medically necessary. 
The reviewer has overturned the health plan denial in whole.

The patient is an elderly patient with a past medical history of Alzheimer's dementia, major depressive disorder, urinary incontinence, bowel incontinence, history of falls, bilateral hand and knee osteoarthritis, wheelchair bound status, hearing loss, macular degeneration, hypertension, congestive heart failure, vertigo, osteoporosis, and mitral valve replacement who had been assigned personal care assistant service (PCAS)hours 10 hours/day, 7 days/week to total 70 hours/week. There was a request to increase  personal care assistant service (PCA) hours. The patient had an assessment tool performed via telephone assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximal assistance with tasks of managing medication, stairs, and transportation. The patient was assessed at extensive assistance with tasks of phone use, bathing, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use while limited assistance with tasks of personal hygiene, bed mobility, and eating. This report noted the patient to be incontinent of urine and continent of bowel. The assessment noted the patient is unable to perform daily tasks independently due to functional and cognitive limitations, limited endurance, weakness, fatigue, inability to stand and bear weight for prolonged period of time. The patient was noted to be transferring and ambulating with a rolling walker but needs human assistance for safety due to poor balance and unsteady gait. This assessment tool noted the patient to have frequent falls with three falls in the previous month but with no medical intervention needed. The patient's locomotion was not tested on this assessment as the patient did not walk on own and did not use a wheelchair. The patient does have help from an informal helper noted to be a child or child-in-law. The patient was evaluated by a care manager and there was an answer of yes to the question of breakdown of skin integrity and the patient had a recent fall from the bed at 5 am with no witness and suffered a laceration to the nose. There was a monthly assessment call by the insurer noting the answer of yes to breakdown of skin integrity and that the patient fell from bed on while turning.
The patient saw the primary care physician with an office note documenting the patient was wheelchair and housebound, lives alone, has profound memory deficit, is highly prone to falls, is unable to function normally in her daily living without substantial assistance and is completely dependent on others, needs continuous supervision, preparation, administration and reminders for medication and meals, and needs assistance with activities of daily living (ADL) 's and Instrumental activities of daily living (IADL) 's and home safety.
The patient's primary care physician (PCP) wrote a letter requesting an urgent increase in home care hours due to rapidly deteriorating mental state and physical health based on the provider's clinical findings. 

The requested service in HHC-Level 2 personal care assistant services 24 Hour per day split shift is medically necessary for this patient.
 The personal care assistant service (PCAS) for this patient overnight are not solely for supervision and safety but to assure the safe completion of one or more of the patient's ADLs or IADLs. The patient had numerous documented falls in the hours when personal care assistant (PCA) was not present as the patient requires assistance with bed mobility, incontinence cares, toilet use, transfer toilet, personal hygiene, and locomotion during the overnight hours. 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 the  home.