Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, decreased mobility. 
Treatment: Home health care. 

The insurer denied Personal Care Assistance: 24 Hours per Day, 7 Days per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, osteoporosis, liver cancer, urinary incontinence, bowel incontinence, coronary artery disease, pulmonary hypertension, chronic kidney disease, osteoarthritis, and dementia who had been assigned PCA (personal care assistant) services based on an assessment tool performed that assessed the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, transfer toilet, and toilet use. With tasks of walking and locomotion, the patient was assessed at limited assistance while independent with tasks of bed mobility and eating. The patient's PCP (primary care provider) provided a letter stating the patient's diagnoses, the patient lived alone and had been waking at night frequently, was at high risk for falls, needed someone to accompany her to doctors appointments, needed someone to check her blood pressure twice daily, would benefit from constant supervision by home attendant, and the provider strongly recommended increasing her home health service hours to prevent fall and to prevent frequent hospitalization. The patient underwent an assessment tool assessing the patient at total assistance with tasks of ordinary housework, managing finances, and equipment management while maximum assistance with tasks of meal preparation, phone use, stairs, shopping, transportation, bathing, dressing lower body, and toilet use. With tasks of managing medication, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of eating. 

Personal Care Assistance: 24 Hours per Day, 7 Days per Week is medically necessary for this patient. 

There is documentation from the patient's Gastroenterologist (GI) specialist, neurologist, and PCP of worsening cognitive and physical functioning. The patient was undergoing chemotherapy for hepatocellular carcinoma. The patient was having worsening dementia symptoms with nighttime awakenings. The patient has no informal help. The assessment tool noted the patient had moderately impaired cognition, was too weak due to chemotherapy, had decline in activities of daily living (ADL) status over the last 90 days, and had deterioration of overall self-sufficiency in the last 90 days. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient requires at least extensive assistance with walking, locomotion, transfer toilet and toilet use, which are all unpredictable and unscheduled needs that patient has 24 hours/day given her nighttime awakenings. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increased in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL). Taking into account the 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, 7 days/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.