Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Increase for personal care services - 10 hours (hrs.) a day, 7 days a week totaling 70 hrs. a week.
The insurer denied an increase for personal care services - 10 hrs. a day, 7 days a week totaling 70 hrs. a week.
The determination is overturned.

This is a female patient with a medical history notable for dementia. The patient is approved for 8.5 hours per day, 5 days per week, and 2.5 hours per day, one day per week. The patient and her care team requested an increase to 10 hours per day, 7 days per week. This request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The patient has a medical history including type 2 diabetes, arthritis, hypertension, sleep apnea, and early-stage dementia. Her arthritis has resulted in mobility issues. She has also had safety concerns with risk factors for falls. 
The patient's child provided a letter of support for this appeal. The child states that they do not believe that the assessment was wholly accurate and reflective of the patient's current status. Although the patient lives with her child, the child works a full-time job which keeps her out of the house 70 hours per week. This is the reason for the requested increase.
The patient's psychiatrist provided a letter of support. The letter states that the patient has been struggling with chronic pain poorly controlled by medication. This has significantly impeded her ability to carry out activities of daily living. The physician feels that the patient would benefit from increased personal care assistance during the day.
A Uniform Assessment System (UAS) was completed. The patient lives in an apartment with her daughter. Her cognition was moderately impaired. She was alert and oriented to person and place only. She is not able to direct her care. For her instrumental activities of daily living, the patient requires total dependence on meal preparation, housework, finances, stairs, and shopping. She requires maximal assistance for transportation and phone use. For her activities of daily living, the patient requires maximal assistance for bathing and dressing her lower body. She requires extensive assistance for toilet transfer and toilet use and dressing her upper body. She requires limited assistance for hygiene, walking, locomotion, bed mobility, and eating. She is frequently incontinent of urine and occasionally incontinent of stool. She wears pull-ups and pads to manage her incontinence. The skin was intact at the time of the evaluation. At issue is the medical necessity of personal care services - 10 hours (hrs.) a day, 7 days a week totaling 70 hrs. a week.

The requested health service increase for personal care services - 10 hrs. a day, 7 days a week totaling 70 hrs. a week is medically necessary for this patient.
The patient requires personal care assistance for all activities of daily living as was reflected in the UAS. The letters from the patient's family and her physicians suggest that her requirement for personal care assistance is likely greater than what is reflected in the assessment. At a minimum, she requires assistance with toileting and managing incontinence care and cannot direct care independently. She will require personal care assistance during all hours that her daughter is not present. Therefore, the requested increase to 10 hours per day, 7 days per week is medically necessary and reasonable for the patient. Failure to address her personal care needs could result in skin breakdown and or infection.