Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal Care Aide Services 10 hours a day, 7 days a week. 

The insurer denied: Personal Care Aide Services 10 hours a day, 7 days a week. 
The denial is overturned. 

This is a case review for a female with medical history notable for dementia, urinary incontinence, type 2 diabetes, and coronary artery disease. The patient is currently approved for 5 hours per day, 7 days per week (35 hours per week) of personal care services. The patient and her care team requested an increase to 10 hours per day, 7 days per week (70 hours per week), and this request was denied by the insurance company. This denial is the subject under review. 

A letter of support for this appeal was provided by the patient's physician who has been treating her for many years. The physician states that her home is the "most appropriate place for this patient, and she is motivated to stay in her home" but that accommodations will need to be made for her functional limitations. She requires assistance with numerous activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) which are discussed in detail. The physician states that for the patient to stay in her home, her home health aide hours would have to be increased. This is to provide "assistance for personal home care as she is unable to perform such basic life functions on her own." 

A Uniform Assessment System (UAS) was completed and was available for review. The patient had a fall while attempting to go to the bathroom. The fall resulted in a femur fracture and hospitalization. She was then transferred to skilled nursing facility for rehabilitation until she was discharged to home. The evaluation took place following this discharge from skilled nursing facility. The patient was found to have minimally impaired cognition; she was alert and oriented to person and place only with periods of forgetfulness. Memory was noted to fluctuate over the course of the day. It is noted that her daughter is "involved in all aspects of care." For her IADL's, the patient requires total dependence for meal preparation, housework, shopping, and transportation. She requires maximal assistance for finances and extensive assistance for managing medications. For her ADL's, she requires maximal assistance for bathing, dressing lower body, and toilet use. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, and toilet transfer. She requires limited assistance for bed mobility and eating. She is frequently incontinent of urine due to inability to make it to the bathroom in a timely manner. She is continent of stool. A task tool associated with the most recent assessment recommended 5 hours and 3 minutes of personal care services per day, an increase from 4 hours and 54 minutes on previous assessment. 

The requested health service of Personal Care Aide Services 10 hours a day, 7 days a week is medically necessary for this patient. 

The patient suffered a fall with femur fracture, hospitalization, and subsequent recovery in a skilled nursing facility. Given her age and comorbidities, it is reasonable to expect that her level of functioning will have permanently declined from where it was prior to the fall. This is reflected in the UAS. The tasking tool only recommended an increase in 9 minutes per day for personal care tasks despite a clear decline in functional status. This likely does not accurately reflect her actual need. The task tool only allows for 3-bathroom trips per day and does not account for additional dressing, etc. that may be required due to incontinence. Her functional needs will be worsened by her dementia and fluctuating ability to direct her care. Her physician certified that it would be optimal for her to remain in her own home, but medically it is necessary for her to have increased personal care services to meet her functional needs.