Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Alzheimer's Dementia

Treatment: for Home Care/ Personal Care Level 2 Personal Care Services Increase to 84 Hour(s) per Week

The insurer denied coverage for Home Care/ Personal Care Level 2 Personal Care Services Increase to 84 Hour(s) per Week.

The denial is modified.

This is a patient with chronic medical problems including hypertension, hypothyroid and progressive cognitive decline. The patient lives alone. The family assists with the patient's care.  The insurer increased personal care aide (PCA) services from 35 to 49 hours/week.  However, the request is for an increase to 12 hours/day, 7 days/week for a total of 84 hours/week, leading to an external review. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as moderately impaired. The patient reportedly requires maximal assistance to total dependence for performing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, lower body dressing and toilet transfer/use.  Extensive assistance is reportedly needed for personal hygiene and upper body dressing.  Limited assistance is reportedly needed for locomotion and ambulation. The patient is at the supervision level or independent for bed mobility and eating. The patient is reportedly infrequently incontinent of bladder and continent of bowel. There has been no reported change in the patient's activities of daily living (ADL) status or self-sufficiency over the prior 90 days.  The patient has reportedly fallen in the last 90 days. The patient's functional ability has significantly declined when compared to the previous UAS report.

The reviewer would agree the patient may benefit from additional monitoring for safety; particularly due to their reported cognitive deficits and falls risk.  However, PCA hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no one else is available to provide assistance. The reviewer would also agree the patient's functional deficits are substantial and have significantly declined.  Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing PCA services to 10 hours/day, 7 days/week, totaling 70 hours/week.  The patient also has the option of restructuring and flexibly using the 70 PCA hours weekly to better maintain and meet their functional needs.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).   

From a physical medicine and rehabilitation perspective, Home Care/Personal Care Level 2, Personal Care Services increase to 84 hours per week is not medically necessary.  However, increasing Home Care/Personal Care Level 2, Personal Care Services increase to 70 hours per week is medically necessary.    

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Home Care/ Personal Care Level 2 Personal Care Services Increase to 84 Hour(s) per week is not substantiated. However, increasing Home Care/Personal Care Level 2, Personal Care Services increase to 70 hours per week is medically necessary.