Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Home Care / Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Split Shift). 
The insurer denied the request for Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Split Shift). 
The health plan's determination is overturned. 

The patient is a female with a past medical history of dementia, hypothyroidism, gastroesophageal reflux disease (GERD), hypertension, osteoarthritis, urinary incontinence, bowel incontinence, and depression. She had been assigned personal care aide (PCA) services for 63 hours per week based on assessment performed via video. The video assessed the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, shopping, and toilet use while maximum assistance with tasks of managing finances, phone use, stairs, transportation, bathing, dressing upper/lower body, walking, locomotion, and toilet transfers. The patient was assessed at extensive assistance with the task of personal hygiene and bed mobility and limited assistance with task of eating. Tasking was to the full estimated 50.17 hours per week. 
There was a request to increase PCA (personal care aide) services and the patient underwent another assessment via video assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, and shopping while maximum assistance with tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, toilet transfers, and toilet use. With the task of eating the patient was assessed at extensive assistance while limited assistance with tasks of walking, locomotion, and bed mobility. Notes from the assessment stated the patient lived alone in a rented room in a house and had a decline in her activities of daily living (ADL) status over the last 90 days. She had a deterioration of overall self-sufficiency in the last 90 days and could not make needs known or direct care. The tasking tool estimated 55.25 hours per week. 

There is documentation from the plan's own assessments of maximum assistance with toilet transfers and toilet use. The patient underwent a video assessment showing an improvement in tasks of walking, locomotion, and toilet use despite documentation of worsening dementia indicating that this assessment likely underestimated the patient's care needs. Because the patient requires maximum assistance with toilet transfers and toilet use, she has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. 
A time-based tasking tool should not have been utilized as this patient has documented 24-hour care needs. The requested increase in PCA (personal care aide) services is not solely for safety and supervision but to assist the patient with safe completion of ADL's (activities of daily living) and instrumental activities of daily living (IADL's). The patient's care needs cannot be met solely with adaptive equipment or medical supplies. Although there was no documentation of specific overnight care needs that would not allow a PCA 5 hours of uninterrupted sleep there is documentation that there is no physical space for a live in aide and therefore split shift services are medically necessary. 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 (personal care aide) services 24 hours/day, 7 days/week, split-shift, are medically necessary for this patient. 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 her own home. 
 
The health plan's determination of medical necessity is overturned.