Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease
Treatment: Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes, 84 hours per week.
The insurer denied Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes, 84 hours per week.
The determination is upheld.

This is a female patient with a medical history notable for Alzheimer's disease, coronary artery disease, hypertension, diabetes, and arthritis. The patient is approved for 45 hours per week of consumer directed personal care services. The patient and her care team requested an increase to 84 hours per week, and the request was denied by the health plan.
The patient's physician has provided a letter of support for this appeal. The letter states that the patient has had worsening memory recently. She was hospitalized due to coronavirus (COVID) and due to pneumonia. Her health has been worsening, and she is increasingly weak and dizzy. The physician states that the patient cannot care for herself in any way at this time.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented person and place only with moderately impaired cognition. She has had increasing confusion recently. She was unable to recall any significant medical information. For her instrumental activities of daily living, she requires total dependence for meal preparation, housework, and finances. She requires maximal assistance for medications, stairs, shopping, and transportation. For her activities of daily living, she requires maximal assistance for bathing, dressing lower body, walking, locomotion, and toilet use. She requires extensive assistance for hygiene, dressing upper body, and toilet transfer. She requires limited assistance for eating and is independent for bed mobility. She requires weight-bearing assistance when transferring and uses a family member for support when using a walker. She is frequently incontinent of urine and is continent of stool.  A task tool associated with the assessment recommended 45 hours per week to address her personal care needs. Compared with a prior assessment, the patient showed a similar level of function.
Recent office visit notes were provided for review. The patient had a mini mental status examination. The score was 18 out of 30, consistent with moderate dementia. The physician diagnosed her with Alzheimer's type dementia. At issue is the medical necessity of Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes, 84 hours per week.

The requested health service of Personal Care HHC - Level 2 Personal Care Services, per 15 minutes, 84 hours per week has not been demonstrated to be medically necessary for this patient.
The patient required hands-on assistance for all of her personal care tasks including ambulation, transfers, and toileting. Her care needs are expected to be extensive throughout the day, but will be intermittent and scattered without the need for constant care. Because the patient uses consumer directed personal care and has a family member providing this support, she can spread her hours out throughout the day as needed. It is unclear what personal care needs, if any, are not being provided at her current level of assistance. There were no logs provided which demonstrate increased frequency of personal care needs beyond what is recommended by the task tool. The patient's level of function is similar to what it was last year, so it is unclear why an increase in hours would be necessary at this time. The requested increase in personal care hours has not been demonstrated to be medically necessary.