Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular
Home Health Services

Diagnosis: Dementia
Treatment: Home care/personal care, home health care (HHC) level 2 personal care services per 15 minutes increase to 24 hours per day (split shift.)

The insurer denied home care/personal care HHC level 2 personal care services per 15 minutes increase to 24 hours per day (split shift.)

The determination is overturned.

The patient is a female with past medical history of dementia, dysphagia, atrial fibrillation, chronic anticoagulation, congestive heart failure (CHF), coronary artery disease (CAD), chronic hypoxic respiratory failure with oxygen therapy hypertension, migraine, osteoporosis, urinary incontinence, and bowel incontinence who had been assigned personal care assistant (PCA) services 12 hours/day, 7 days/week to total 84 hours/week. The patient's primary care physician (or provider) (PCP) provided a letter stating the patient needed urgent upgrade in her home health care services to 24 hours/day, split shift, 7 days/week as the patient had dementia with sundowning and confusion, especially at night, and used bi-level positive airway pressure (BiPAP) therapy and required observation and proper application of BiPAP in the overnight hours.

The patient had multiple hospitalizations due to aspiration pneumonia and following her admission she had an assessment performed assessing the patient at total assistance with all tasks except for managing medication, phone use, equipment management, personal hygiene, dressing upper body, and eating for which she was assessed at maximum assistance. The patient was assessed at extensive assistance with task of bed mobility. The patient was hospitalized with weakness and aspiration pneumonia. The patient was seen by speech therapy and placed on thin liquid/pureed diet. A palliative care consultation was obtained for goals of care and the patient was placed on hospice. Hospital notes documented wounds that were addressed during hospital stay at the great toe, skin tear on the right arm, stage 2 sacral ulcer, and 2 heel ulcers with recommendation for positioning every 2 hours in addition to local wound care.
There was a request to increase PCA services and the patient underwent an assessment assessing the patient at total assistance with all tasks except for managing medication, phone use, bathing, personal hygiene, dressing upper body, and eating for which the patient was assessed at maximum assistance. The patient was assessed as extensive assistance with bed mobility. The assessment stated the patient lived with her spouse in a 1 bedroom apartment and had mutual PCA services with her husband. 
 
The patient has baseline dementia with confusion and is not able to manipulate/reapply the mask on her own. The patient's husband is not able to provide informal support due to his own medical conditions.
The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL's) and Instrumental activities of daily living (IADL's). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient's care needs in the overnight hours would not allow a PCA 5 hours of uninterrupted sleep, therefore split shift services are medically necessary. 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, 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.