Appeal type: Medical necessity
Decision: Overturned

Diagnosis: memory issues and impairment of gross motor skills.
Treatment: 56 hours/week, 8 hours x 7 days; personal care aide- level 2.
The insurer denied 56 hours/week, 8 hours x 7 days; personal care aide- level 2.

The determination was overturned.

The patient is a female with a medical history notable for memory issues, impairment of gross motor skills, frequent falls and chronic vertigo. She was receiving 38.5 hours per week (5.5 hours per day, 7 days per week) of level 2 personal care services. The patient and her care team requested an increase to 56 hours per week (8 hours per day, 7 days per week). The plan partially denied the request; she was increased to 42 hours per week (6 hours per day, 7 days per week).

A letter of medical necessity for this appeal was provided by the patient's physician. She describes that the patient has multiple medical issues affecting mobility, including multi-joint arthritis, fibromyalgia, chronic vertigo and gait abnormalities. The patient is also followed by a neurologist for these issues as well as her "poor short-term memory." The physician states that these "multiple chronic debilitating conditions" have been "worsening progressively over the past few years." This has led to deficits in the patient's ability to care for herself and perform activities of daily living independently. The physician states: "the increased occurrence of falls in addition to significant decline in functional mobility skills and gross motor control resulting from chronic conditions impairs her ability to perform vital activities. Therefore, the increase in home care hours is medically necessary."

The files included a mini-mental state examination (MMSE). One exam showed a score of 25, consistent with the low end of the normal range. Repeat testing showed a score of 20, consistent with worsening cognition and a possible diagnosis of dementia.

A Uniform Assessment System (UAS) that was completed was the most recent functional assessment available for review. The review found that she had modified independence in cognition, was alert and oriented and able to call for help in an emergency.

A tasking tool associated with the UAS was provided. For this assessment, a total of 34.94 service hours per week was recommended. For the more recent assessment, the recommendation was unchanged.
From a functional standpoint, she requires total dependence for housework. She requires maximal assistance for meal preparation, shopping and transportation. She requires extensive assistance for managing medications and finances. For her activities of daily living (ADL's) she requires maximal assistance for bathing and lower body dressing. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer and toilet use. The patient requires limited assistance for bed mobility and eating. She ambulates with a cane and has a slow and unsteady gait, tiring easily. She is frequently incontinent of urine (daily), and continent of stool. She uses pads for incontinence episodes. Compared with a prior assessment, her functional assessment did not change.
The patient's current level of personal care assistance was adequate for her needs last year. However, the patient's family and physician have attested that her functional status has significantly worsened over the past year. The most recent UAS is more than 6 months old and showed no changes from the UAS from last year. This is likely underrepresenting her true needs given the testimony by her physician. This is also supported objectively by worsening MMSE scores, now in the dementia range. While it is true that dementia support is not a personal care function, it is likely that it has been coupled with a functional decline as the physician asserts. Additional hours to prevent falls are not merely a safety monitoring function if she is falling while attempting to perform ADL's that she cannot perform independently. Therefore, a modest increase in care support hours of 2 additional hours per day is appropriate to continue to support her in the home and address her functional needs.

The health plan's determination of medical necessity is overturned in whole.