Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular Disorder
Home Health Care

The patient is a male with a past medical history of diabetes mellitus type 2 with neuropathy, major depressive disorder with cognitive impairment, Alzheimer's disease, hyperlipidemia, hypertension, bowel and bladder incontinence and morbid obesity who was assessed for personal care assistance (PCA) services for the first time. The patient had been hospitalized with rhabdomyolysis and acute kidney failure and was transferred to rehabilitation and transitioned to long term care. He was hospitalized again with altered mental status with a 2 week inpatient psychiatric hospitalization and his family signed him out against medical advice (AMA) to care for him at home rather than going back to the nursing home. His sister is able to stay with him 2-4 days per week and has been having friends stay with him when she is unable. The sister and provider requested PCA services. The patient is not on insulin for his diabetes mellitus type 2 but does have a glucometer to check blood sugars.

On the assessment tool, the patient was noted to need total assistance with meal preparation, ordinary housework, managing finances, managing medications and shopping. His assessment showed need for maximal assistance in tasks of bathing, personal hygiene, dressing upper and lower extremities and toilet use. The patient's level of assistance for tasks of walking, locomotion, transfer toilet and eating was assessed at extensive assistance. The patient required limited assistance with task of bed mobility. The assessment tool noted the patient was moderately cognitively impaired. The patient can be combative with change in clothes or bathing and verbally abusive. The sister has placed a special lock on the door because of his tendency to wander. The patient used another person and/or a rollator walker for ambulation and they were looking into getting him a wheelchair.

The health plan's determination is overturned.

The patient has a history of dementia with a progression in his symptoms over the last year. On the assessment tool, the patient was noted to need extensive assistance with locomotion, walking and eating but according to his PCP and psychiatrist the patient required at least maximal care for these tasks. The patient is incontinent of bowel and bladder and has unscheduled needs outside of the approved PCA service hours. The patient is resistant to dressing, bathing and personal hygiene and requires more assistance with these tasks than determined in assessment tool. The patient does not have an informal caregiver. His sister is not able to provide assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) outside of the approved PCA hours. His PCP documented medical necessity for this patient to have 24 hour PCA services, 7 days/week. His psychiatrist also noted medical necessity for the patient to have 24 hour PCA services. Because of the patient's medical conditions and declining health his providers have noted the medical necessity of increase PCA service hours which are not directly related to safety and supervision but for assistance with unscheduled needs and ADL's and IADL's. Based on the submitted documentation the requested services are medically necessary.