Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease
Treatment: Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in)
The insurer denied the home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in).
The determination is overturned.

The patient has a past medical history of hypertension, Alzheimer's disease, inflammatory polyarthropathy, osteoarthritis, osteoporosis, atrial fibrillation, congestive heart failure, urinary incontinence, and bowel incontinence who had been assigned personal care assistant (PCA) services 12 hours/day, 7 days/week to total 84 hours/week based on assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, phone use, and shopping while maximum assistance with task of managing medication. The patient was assessed at extensive assistance with tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, transfer toilet, and toilet use while supervision with tasks of walking, locomotion, and eating. With the task of bed mobility the patient was assessed as independent. The patient was hospitalized with rapid atrial fibrillation and congestive heart failure.
There was a request to increase PCA services and the patient underwent telephonic assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, and toilet use while maximum assistance with tasks of transportation and bathing. The patient was assessed at extensive assistance with tasks of stairs, personal hygiene, dressing upper/lower body, and eating while limited assistance with tasks of walking, locomotion, transfer toilet, and bed mobility. Notes from the  assessment noted the patient lived alone and had a decline in mental status since her hospitalization.
The insurer sent an initial adverse determination denial notice denying request to increase PCA services. This denial stated there was no change in the patient's clinical status and no change in social circumstances. In addition, the initial denial letter stated plan assessments are not required to include safety monitoring as a separate task for dementia, wandering, and fall.
The insurer sent a final adverse determination denial notice continuing to deny a request to increase PCA services specifically stating the member has diabetes with no loss of motor function, it is not medically necessary to increase her hours to 24 hour live-in, and the personal care hours currently authorized in the amount, duration, scope necessary to meet the member's personal care needs.
The patient's primary care physician (PCP) provided a letter documenting the patient's medical diagnoses and the patient's need for constant supervision and assistance in performing her daily-living activities, the need for a strict schedule taking medications, and the need to attend multiple medical appointments in order to keep her in stable condition. In addition, the PCP's letter stated it was medically necessary for the patient to get 24 hour home health service to avoid patient wandering out of her apartment, turning on stove or water facet and putting others in danger. Lastly, the patient's PCP stated the patient's mental condition was deteriorating rapidly. At issue is the medical necessity of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in).

The services are medically necessary.
The patient has documented progressive chronic medical conditions of Alzheimer's disease, osteoarthritis, and congestive heart failure with worsening mental and functional status as documented by the patient's PCP and the telephonic assessment. The patient had an increase in assistance needs with tasks of managing medication, transportation, bathing, walking, locomotion, toilet use, bed mobility, and eating when comparing the assessments. The patient is total assistance with the task of toilet use. The patient had urinary and bowel incontinence. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not formulate a plan to meet these unscheduled and unpredictable care needs. The patient lives alone. The increase in PCA hours is not solely for supervision and safety but to assist the patient with safe completion of activities of daily living (ADLs)/instrumental activities of daily living (IADLs). The patient's increase in assistance needs cannot be met with current PCA hours and/or medical supplies and adaptive equipment. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, live-in, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary under when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.