Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease. 
Treatment: Home Health Care/Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes increase to 24 hours per Day(live in). 
The health plan denied the requested increase in personal care assistant services as not medically necessary. 
The health plan's determination is overturned. 

The patient is a female with a past medical history of Alzheimer's dementia, abdominal aortic aneurysm, thoracic aortic aneurysm, hypertension, osteoarthritis, insomnia, urinary incontinence, bowel incontinence, anxiety, depression, and hyperlipidemia who had been assigned personal care assistant (PCA) services 35 hours/week based on an assessment, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and shopping while maximum assistance with tasks of managing finances, managing medication, phone use, transportation, bathing, and dressing lower body. With tasks of stairs, personal hygiene, dressing upper body, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of walking, locomotion, and transfer toilet. The patient was assessed at supervision with eating and independent with task of bed mobility. The tasking tool estimated 43.5 hours. 

The patient's son provided a letter requesting an expedited appeal stating his mother needed services 24 hours/day, live-in, 7 days/week. The son's letter also stated the patient was losing weight because she forgot to eat her evening meals, the patient needed reminders with evening medications, and it was crucial for her to receive these because one of the medications treats overactive bladder and if she missed her medication, she would have wet diaper and would develop a urinary tract infection (UTI) and pressure ulcers. In addition, the son's letter stated the patient was unable to change her diaper due to cognition and poor manual dexterity due to arthritis and she needs to change her diapers at least 2-3 times at night. The son's letter also stated the patient recently developed bowel incontinence and the patient needs assistance with toileting hygiene. Lastly, the son reported the patient requires her nighttime medications to help her keep calm and sleep as she has been found wandering the street at night. 

There is documentation from the patient's primary care physician (or provider) (PCP) of the need of increased PCA services. The patient's son provided a letter noting the patient needed assistance with evening meals and evening medication. The patient requires at least extensive assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unscheduled and unpredictable care needs that span a continuum of time. The patient has documented 24-hour care needs and therefore, a task-based assessment should not have been utilized to calculate the patient's PCA hours. 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 (ADLs) and instrumental activities of daily living (IADLs). 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, live-in, 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.