Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular-dementia.
Treatment: Home Health Care
The insurer denied Level 2 Personal Care Services per 15 min increase to 24 hours per day (split shift).
The determination is overturned.

The patient has a past medical history of dementia, atrial fibrillation on chronic anticoagulation, depression, urinary incontinence, bowel incontinence, hypertension, and hyperlipidemia who had been assigned personal care assistant (PCA) services 35 hours a week based on a telephonic assessment tool performed assessing the patient at total assistance with the tasks of meal preparation and ordinary housework while maximum assistance with tasks of stairs and shopping. With the tasks of managing finances, managing medication, and transportation, the patient was assessed at extensive assistance while limited assistance with tasks of bathing and dressing lower body. The patient was assessed as independent with the tasks of phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. Notes from the assessment stated the patient was alert and oriented times (x) 2, had minimal cognitive impairment, and was continent of bowel and bladder.

The patient's primary care physician (PCP) provided a letter stating the patient suffered from various health issues and among them severe dementia which was progressively worsening. The letter further stated the patient was often confused and left the house on her own during the night and was unable to take care of any personal needs on her own. The letter lastly requested accommodation to meet her needs in the nighttime hours with a home health aide as soon as possible.

The patient underwent a telephonic assessment tool assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with task of medication management. The patient was assessed at extensive assistance with the tasks of phone use, stairs, transportation, and bathing while limited assistance with tasks of personal hygiene, dressing upper/lower body, and toilet use. The patient was assessed at supervision with the tasks of walking, locomotion, and eating while independent with the tasks of transfer toilet and bed mobility. Notes from the assessment stated the patient had 2 falls in the last 90 days, was moderately cognitively impaired, required supervision with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs) at all times, was incontinent of bowel and bladder but the daughter denied the use of incontinence supplies, and the daughter had installed cameras to monitor the patient's activities.

The insurer sent an initial adverse determination denial notice partially denying request to increase PCA services with approval to increase to 42 hours/week. The denial stated that the patient needed assistance with chores and little assistance with activities of daily living and there was no change in overall self-sufficiency. The denial also stated there had been no change in her clinical condition and no change in her social circumstances. In addition, the letter noted the patient's needs were predictable and could be scheduled and she had no compelling nighttime needs. Lastly, the denial stated plan assessments are not required to include safety monitoring as a separate task for dementia, wandering, and falls.

The insurer provided a final adverse determination denial notice partially denying the request to increase PCA service with an increase to 49 hours/week. The denial stated the patient had dementia with no loss of motor function and it was not medically necessary to increase the patient's PCA hours to 24-hour split shift. In addition, the denial stated the patient no change with most of her physical functioning since prior assessment and the personal care hours were currently authorized and the amount, duration and scope necessary to meet the patient's personal care needs with hours beyond those currently authorized being for safety monitoring which was not a covered benefit under the personal care service program.

The patient's PCP provided another letter stating the patient had dementia and was no longer capable of making her own decisions and the patient's daughter assisted her and had taken over making any type of arrangements for the patient. The patient's daughter provided a letter stating the patient never felt hunger or heat and could go without food for hours if she was not forced to eat. Her air conditioning had been broken and the temperature in her apartment had been up to 89 degrees. The patient stated she can shop, cook, and do her own laundry but she was limited in her ability to do so, but did not recognize this due to her dementia. The letter also stated the patient would not take her medication without being told. The patient awakens around 2:00 AM gets dressed and is ready to go, has had her gas stove turned on without anything cooking, has burned an empty pot, and will not take a shower or bath without being forced. The daughter's letter also stated she lives 20 minutes away and had her own family and children and was not able to provide 24-hour care.

At issue is the medical necessity of Level 2 Personal Care Services per 15 min increase to 24 hours per day (split shift).

The services are medically necessary.

The patient has the medical condition of dementia which is progressive and documented to be worsening by both the assessment and letters from her PCP and daughter. The patient has had falls when unassisted and is on chronic anticoagulation which puts her at risk for increased injury. The patient is documented to have bowel and bladder incontinence. The plan incorrectly stated that the patient's care needs can be scheduled and planned. The patient has unpredictable and unscheduled care needs that span a continuum of time, and the insurer did not document a plan to meet these needs. The patient's assessment underestimated her assistance needs with multiple tasks based on the daughter's letter and the PCP letter. The patient requires more assistance than noted with tasks of managing medication, personal hygiene, walking, locomotion, toilet use, and eating. The patient will not take her medication unless forced to do so. The patient will not eat unless forced to do so. The patient has incontinence of bowel and bladder with assistance needs with toileting and personal hygiene. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The plan's assessment noted the patient required supervision with all ADLs and IADLs at all times. The plan assumed her daughter could provide informal help outside of the currently assigned PCA hours, but the daughter documented in her letter that she is unable to do so. The plan also stated there had been no change in her clinical condition and no change in her social circumstances but there is documentation in the assessments and daughter's letter the patient has worsening cognitive skills, was now incontinent of bowel and bladder, and the patient's daughter could not provide increased informal help. 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 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.