Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lewy Body Dementia.
Treatment: Home Health Care.
The health plan denied the requested increase in personal care assistant hours. The health plan's determination has been overturned.

The patient has a past medical history of Lewy Body Dementia with behavior changes and anxiety who had been assigned personal care assistance services 10 hours/day, 7 days/ week to total 70 hours/week.  The patient was assessed at maximal assistance with tasks of managing medication, transportation, equipment management, bathing and dressing lower body while assessed and extensive assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use and eating.  This assessment  noted the patient to be severely cognitively impaired and not able to express goals. The patient had 1 fall in the last 3 months in 2 emergency room visits in the last 3 months. There are office notes provided noting a weight loss of 13-1/2 pounds. These office notes also noted a steady decline in  mentation with increased confusion, disorientation and anxiety. The patient was not taking  medications at times and had significant reduction in appetite. Speech therapy and physical therapy were recommended as the patient had choking episodes and unsteady gait with falls. An egg crate was ordered to prevent pressure ulcers.  The patient's primary care physician provided a letter stating the patient has advanced dementia and is prone to altered behavior, needs caregiver supervision at all times, has had progressive decline in mental status that makes the patient unable to retain or follow instructions given, is unable to use a walker correctly and the patient requires 24-hour per day 7 days per week personal care. The patient's psychiatrist wrote a letter stating the patient's diagnosis of dementia with Lewy body, and the patient would greatly benefit from having continuous home care services. The patient's daughter provided a letter. Between midnight and 6 AM the patient gets up to eat, needs help getting in and out of bed and has been found on the floor without the ability to get up off the floor. The spouse also has dementia and is not able to take care of needs. The  pull-up needs to be changed multiple times a day and  bed needs to be changed every morning and every night. The patient is up multiple times during the night to use the toilet and needs assistance to get up from the toilet, and has fallen more than once when trying to toilet on own. Because of arthritis patient cannot wheel a wheelchair and will not stay in the wheelchair unless fastened into it.

The requested health service/treatment of increase in consumer directed personal assistance services is medically necessary.
The patient has the diagnosis of dementia which is a progressive disease. The assessment tool noted the patient's severe cognitive impairment. The patient's medical providers and daughter document the change in  physical and mental status since the assessment tool. The patient has no informal helper. The patient previously had some assistance from spouse but the spouse is not able to help due to a decline in  own medical conditions. The patient's CDPAS services are not solely for supervision and safety but to assist the patient with activities of daily living and instrumental activities of daily living . There is documentation of overnight needs as the patient is up frequently to eat and use the bathroom. When the patient does have incontinence episodes, the patient needs assistance with incontinent care in the overnight hours. The patient needs assistance with all walking and locomotion, as the dementia prevents patient from remembering to use a walker or how to use the walker. Personal care services are medically necessary under medicaid when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in the patient's own home.