Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Consumer and Self-Directed Personal Assistance Services: 24 hours a day, 7 days a week (live-in).
The insurer denied Consumer and Self-Directed Personal Assistance Services: 24 hours a day, 7 days a week (live-in).
The health plan's determination is overturned.

The patient is a female with a medical history notable for dementia, incontinence, diabetes, heart failure, and pulmonary hypertension. The patient was approved for 24 hours a day, 7 days per week, live-in consumer-directed personal care assistant services for a total of 91 hours per week. The plan reduced the number of approved hours to 42 hours per week.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has dementia and is incontinent of bowel and bladder. She is oxygen-dependent. The letter states that the patient requires full assistance and reminders for all activities of daily living including toileting. Due to her severe dementia, she requires assistance with ambulation as she is at high risk for falls and is unable to call for help in an emergency. The physician states that live-in-home care is medically necessary for the patient.
Physician office visit notes were provided for review. They detail hospital follow-ups from fecal impaction and congestive heart failure. The patient is oxygen dependent as noted.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives alone in an apartment. She was alert and oriented to person and place only with forgetfulness noted. The patient is not able to direct her care. She is unable to call for help in the event of an emergency. For her instrumental activities of daily living, she requires total dependence on housework. She requires maximal assistance for meal preparation, finances, and shopping. She requires extensive assistance with medications and transportation. For her activities of daily living, she requires maximal assistance for bathing and dressing her lower body. She requires extensive assistance for hygiene, dressing her upper body, walking, and locomotion. She requires limited assistance for toilet use and supervision only for toilet transfer. She is independent in bed mobility and eating. She is frequently incontinent of urine and occasionally incontinent of stool and uses pull-ups for incontinence care. There was no pressure ulcer present at the time of evaluation. The task tool associated with the assessment recommended 64 hours per week to address the patient's personal care needs.
At issue is the medical necessity of Consumer and Self-Directed Personal Assistance Services: 24 hours a day, 7 days a week (live-in).
The health plan's determination of medical necessity is overturned as a whole.
The requested health service of Consumer and Self-Directed Personal Assistance Services: 24 hours a day, 7 days a week (live-in) is medically necessary for this patient.
The patient requires hands-on personal care assistance for all instrumental activities of daily living as well as nearly all activities of daily living. Furthermore, she has dementia and is unable to direct her care. She is incontinent of urine and stool and is not capable of changing her incontinence supplies without assistance. Therefore, her care needs can be reasonably expected to be continuous and unscheduled throughout the day and occasionally in the nighttime as well. Live-in personal care aide services are appropriate for patients with such continuous and pervasive care needs. Therefore, the requested service of living 24-hour personal care is medically necessary and reasonable for the patient. Failure to provide for her personal care needs could result in falls, skin breakdown, and/or infection.