Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, thrombocytopenia, dementia. 
Treatment: Increase Home/Personal Care Level 2 to 24 Hours per Day (Live-In). 
The insurer denied: Increase Home/Personal Care Level 2 to 24 Hours per Day (Live-In). 
The denial is overturned. 

This elderly female patient has medical conditions that include hypertension, diabetes, hypothyroidism, anemia, and thrombocytopenia. She lives alone. The denial of an increase in home/personal care level 2 to 24 hours per day (live-in) is being appealed. The health plan approved 56 hours per week. The Uniform Assessment System (UAS) evaluation completed nearly 2 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing finances and medications; extensive assistance with bathing, personal hygiene, dressing, walking, locomotion, and toileting; and limited assistance with bed mobility and eating. The patient's daughter administers medications and assists as needed. The patient has occasional bowel and bladder incontinence. She had a fall 2 months ago due to dizziness. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been a decline with her cognition and functioning with personal hygiene, dressing, toileting, walking, locomotion, bed mobility, and eating. A letter from the Provider reports the patient has dementia that impacts her ability to perform activities of daily living (ADLs). Additional hours are needed for prevent onset of disability, to prevent in-house accidents as she will turn the stove on, and her safety because she wanders when alone. The patient has need for frequent toileting and has incontinence. She is at risk for falling. 

The requested health service is medically necessary. 

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding. This patient has multiple chronic conditions. She lives alone. Her daughter provides informal support. The denial of an increase in home/personal care level 2 to 24 hours per day (live-in) is being appealed. The health plan approved 56 hours per week. Uniform Assessment System (UAS) evaluation completed nearly 2 months ago shows the patient has moderately impaired cognition and requires extensive assistance to total dependence with all activities of daily living. She is incontinent of bowel and bladder. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been a decline with the patient's cognition and functioning with personal hygiene, dressing, toileting, walking, locomotion, bed mobility, and eating. The appeal statement supports the patient needs assistance with all activities of daily living. She requires unscheduled assistance with toileting due to urinary frequency and incontinence. Additional assistance is requested for the patient's safety due to in-house accidents and wandering. The information provided shows that this patient has significant limitations in cognition and functioning that have progressed over Uniform Assessment System evaluations. Her limitations and need for frequent assistance with unscheduled toileting cannot be met with the approved personal care services of 56 hours per week. The proposed increase home /personal care personal care services to 24 hours per day (live-in) is medically indicated.