Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Personal Care Worker (PCW) Services to 7 Days A Week, 24 Hours Per Day Continuous Care by More Than One Person for 168 Hours Per Week
The insurer denied: Increase Personal Care Worker (PCW) Services to 7 Days A Week, 24 Hours Per Day Continuous Care by More Than One Person for 168 Hours Per Week
The denial is overturned.

The patient is an elderly female with a history of general debility due to dementia. The request is for Personal Care Assistance through Home Health care (Level 2) to be increased from 91 hours per week, based on UAS (Uniform Assessment System) evaluation of several months ago, to 168 hours per week (24 hours per day, 7 days per week) based on UAS (Uniform Assessment System) evaluation of last month. The health plan denied the request because her ADLs/IADLs (activities of daily living/instrumental activities of daily living) needs during the day, such as bathing, dressing, transferring, toileting, meal preparation, feeding, and environmental care are sufficiently infrequent and will continue to be safely and adequately met through the newly authorized service hours. The additional hours requested are because of the patient's chronic medical conditions, and to help with her Activities of Daily Living (ADLs), as she requires extensive assistance with her ADLs (activities of daily living). A review of the records showed that the patient has multiple chronic medical conditions including dementia, hypertension, absence of a kidney, history of falls, right hip pain status post right total hip replacement, osteoporosis, generalized osteoarthritis, and varicose veins. The UAS (Uniform Assessment System) evaluation of last month showed that the patient is moderately cognitively impaired with decisions consistently poor or unsafe and requiring cues. She required limited assistance with personal hygiene, upper body dressing, bed mobility, eating, 
extensive assistance with managing finances, managing medications, maximal assistance for bathing, lower body dressing, locomotion, toilet transfer/use, and total dependence for meal preparation, housework, phone use, stairs, shopping, and transportation. There is documented evidence of a deterioration of her self-sufficiency significantly since the previous UAS (Uniform Assessment System) evaluation of several months ago. She lives alone in a one-bedroom apartment on the first floor with three steps to enter.

The requested Increase Personal Care Worker (PCW) Services to 7 Days A Week, 24 Hours Per Day Continuous Care by More Than One Person for 168 Hours Per Week, is medically necessary.

The patient is moderately cognitively impaired with decisions consistently poor or unsafe. She requires cues and she requires limited assistance with personal hygiene, upper body dressing, bed mobility, eating, extensive assistance with managing finances, managing medications, maximal assistance for bathing, lower body dressing, locomotion, toilet transfer/use, and total dependence for meal preparation, housework, phone use, stairs, shopping, and transportation. There is documented evidence of a deterioration of her self-sufficiency significantly since the previous UAS (Uniform Assessment System) evaluation of several months ago. 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 noted in the most recent UAS (Uniform Assessment System) evaluation. Therefore, the requested 168 hours per week (24 hours per day, 7 days per week) requested is medically necessary. Despite approval for a live-in, the patient's 1-bedroom apartment will make this not tenable for a live-in. Also, the nighttime needs of the patient will not create an enabling environment for the aide to get an adequate five hours of continuous interrupted sleep at night, especially in light of the needs of the patient at nighttime.