Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia.
Treatment: Home care/personal care HHC- personal care aide- live in per diem increase from 24 hours per day (live in) to 24 hours per day (split shift).
The insurer denied home care/personal care HHC- personal care aide- live in per diem increase from 24 hours per day (live in) to 24 hours per day (split shift).
The determination is upheld.


The patient has a past medical history of vascular dementia with behavioral disturbance, polyosteoarthritis, diabetes mellitus type 2, diabetic polyneuropathy, urinary incontinence, atherosclerotic heart disease, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, and thyroid disease who had a fall with resultant hospitalization for left hip fracture. The patient was transferred to short-term rehabilitation and was discharged from rehabilitation. The patient underwent a telephonic assessment tool  assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, and shopping while maximum assistance with tasks of managing finances, managing medication and phone use. The patient was assessed at extensive assistance with tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use while limited assistance with bed mobility and supervision with task of eating. Notes from the telephonic assessment stated that the patient's daughter lived in New Jersey and could not provide care and the patient therefore had no informal help.
The patient underwent another telephonic assessment tool assessing the patient at total assistance with meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, bathing, and dressing lower body while maximum assistance with tasks of phone use, transportation, personal hygiene, walking, locomotion, transfer toilet, toilet use, and bed mobility. The patient was assessed at limited assistance with the task of eating and notes from the assessment stated the patient was unable to express goals due to cognitive decline. In addition, notes from the telephonic assessment stated the patient had informal help from family, the patient was having increased episodes of agitation and wandering, and had a scheduled psychiatric evaluation.
The insurer sent an initial adverse determination denial notice denying the request to increase PCA services stating the assessment showed, in the last 90 days, there was no change in the patient's overall self sufficiency, no clinical change in activities of daily living, no change in clinical condition, and no change in social circumstances. The denial further stated there were no compelling night needs and plans are not required to provide safety monitoring as a separate task.
The plan provided a final adverse determination denial notice continuing to deny the request to increase PCA services stating it was not medically necessary and the patient did not meet criteria. The patient's daughter appealed the denial decision noting "my mother has dementia and requires care because she doesn't sleep a lot and leaves the house when care aide sleeps. We already had three incidents of her being lost". The patient's primary care physician (PCP) provided a letter stating the patient's underlying medical conditions, patient was home bound, had visual, cardiac, and physical impairments that rendered her unable to perform most of her activities of daily living (ADLs) without the assistance of a person, experienced generalized weakness all over her body with pain in both arms making it difficult for her to lift or carry any items of any weight, ambulated with walker for a few steps at home, required contact guard of a person due to poor balance and shortness of breath, suffered from shortness of breath upon minimal exertion and must rest every few steps, often reported numbness, tingling, and prickling sensation in both of her legs which make her balance very poor and unsteady, required assistance of a person for all transfers but especially from a sitting to a standing position and for placing into wheelchair. Lastly, the PCP letter stated the patient needed care provided at night also, suffered from incontinence and needed verbal prompting to remain continent, required reminders to use the bathroom every couple of hours, becomes forgetful and soils herself, gets up frequently at night and needed to be assisted to use the bathroom.
At issue is the medical necessity of home care/personal care HHC(home health care)- personal care aide- live in per diem increase from 24 hours per day (live in) to 24 hours per day (split shift).

The services are not medically necessary.
The patient currently receives personal care assistant (PCA) services 24 hours/day, live-in, 7 days/week. Although the assessment tool from the assessment showed an increase in PCA assistance with the tasks of managing finances, managing medication, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating when compared to the  assessment, there is no documentation of overnight care needs that would not allow a PCA to obtain 5 hours of uninterrupted sleep. The patient has had an increase in aggression and wandering behaviors and has left the home in the middle of the night. PCA services are not for safety and supervision but to assist the patient with safe completion of ADLs/instrumental activities of daily living (IADLs). There are no overnight logs documenting ADL care needs at least every 2-3 hours overnight and no documentation of the need for frequent turning and repositioning in the overnight hours. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are not medically necessary for this patient.