Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Home/Personal Care Services, Level 2, to 24 Hours per Day (Split Shift)
The insurer denied Home/Personal Care Services, Level 2, to 24 Hours per Day (Split Shift).
The denial is overturned.

The patient is an elderly female with a history of general debility due to dementia. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 56 hours per week based on Uniform Assessment System (UAS) of 2 months ago to 168 hours per week. The health plan denied the request because the patient requires maximal assistance for most activities of daily living and extensive assistance with eating. The initial increase in hours to 56 hours per week was deemed sufficient to meet her current needs. The additional hours requested are because the patient cannot be left alone due to cognitive decline and needs additional assistance, which includes medication management, feeding, dressing, bathing, and most of her activities of daily living. She is also unsafe to be left alone. A review of the records showed that the patient has multiple chronic medical conditions including vascular dementia, hyperlipidemia, hypertension, anemia, diabetes, gastroesophageal reflux disease (GERD), chronic venous insufficiency, goiter, history of breast cancer, generalized osteoarthritis, urinary incontinence, chronic obstructive pulmonary disease (COPD) on oxygen nasal cannula, congestive heart failure (CHF), chronic renal insufficiency. Uniform Assessment System-New York (UAS-NY) evaluation of 1 month ago showed that the patient is moderately cognitively impaired; limited assistance for personal hygiene, upper body dressing, lower body dressing, walking, locomotion, toilet transfer, toilet use, bathing, bed mobility, eating; and totally dependent on housework, meal preparation, managing finances, shopping, managing medications. Her family support is good, and she lives alone in an apartment on the first floor in a two-family house with the daughter living on the second floor.

The requested health service is medically necessary.

The requested increase for Personal Care Assistance through Home Health Care (Level 2) from 56 hours per week based on the Uniform Assessment System (UAS) of 2 months ago to 168 hours per week is medically necessary based on the most recent Uniform Assessment System of 1 month ago. The patient is moderately cognitively impaired; requires extensive assistance for bed mobility, eating; maximum assistance for phone use, managing medications, personal hygiene, upper body dressing, lower body dressing, toilet transfer, toilet use, bathing; and totally dependent for housework, meal preparation, managing finances, shopping, managing medications, stairs, transportation, walking, locomotion. The patient's family support is good, and she lives alone in an apartment on the first floor in a two-family house with the daughter living on the second floor. The reason for denial by the health plan as stated in the clinical information above, does not align with the patient's disability features as stated in the Uniform Assessment System of 1 month ago. Therefore, the 168 hours per week based on Uniform Assessment System of 1 month ago as requested should be approved.