Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular
Home Health Services

Diagnosis: Dementia
Treatment: Increase in personal care aide services for a total of 70 hours per week.
The insurer denied the Increase in personal care aide services for a total of 70 hours per week.
The determination is overturned.

The patient has a past medical history of dementia, Parkinson's disease, urinary incontinence, constipation and anxiety/depression and had been assigned personal care aide (PCA) services 8 hours/day, 7 days/week to total 56 hours/week based on an in person assessment tool. The patient was assessed as needing total assistance with the tasks of meal preparation, ordinary housework, managing finances and shopping and maximal assistance with task of managing medication. For the tasks of stairs, bathing, personal hygiene, dressing upper body/lower body, walking, locomotion, transfer toilet and toilet use, the patient was assessed as needing extensive assistance while for tasks of phone use was assessed at limited assistance. The patient was assessed as needing just supervision for bed mobility and eating. There was a request for an increase in service hours to 10 hours/day, 7 days/week to total 70 hours/week. The patient had a telephonic assessment performed with no change in assistance needs for activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) tasks. The patient had no change in the assessment compared to the prior universal assessment tool. Notes from the latest assessment indicated that the patient was more forgetful, tries to leave her home because she forgets it is her home and turns on the stove and forgets it is on. There was a final adverse determination letter sent from the health plan denying an increase in PCA hours noting most of her abilities stayed the same. There is a letter from the patient's primary care physician (or provider) (PCP) indicating that the patient was bedbound and needed assistance to get out of bed and into a wheelchair, had severe weakness, was easily fatigued, needed help with diaper change, needed diaper changed several times per day, needed to be turned every 2-3 hours to prevent development of pressure ulcers and recommended 24 hour PCA services per day to help with ADL's and IADL's. At issue is the medical necessity of an increase in personal care aide services for a total of 70 hours per week.
The requested services are medically necessary. The patient has the progressive illnesses of dementia and Parkinson's disease. She had a telephonic assessment following a request for an increase in PCA hours which underestimated the patient's assistance with ADLs, specifically that the patient would need maximal assistance with transfer toilet, toilet use, bed mobility, walking and locomotion based on information from the patient's son and the patient's PCP. The patient's increase in PCA hours are not solely for safety and supervision. The patient's PCP noted the medical necessity for increased PCA hours as they documented the need for help with frequent diaper changes, bedbound status, need for turning every 2-3 hours to prevent pressure ulcers and help with ADL's 24 hours/day.