Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's Dementia
Treatment: Home care / personal care home health care (HHC) - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in)

The insurer denied coverage for home care / personal care home health care (HHC) - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in)

The denial is upheld 

This is a patient with chronic medical problems including progressive Alzheimer's dementia.  The patient lives with their son in a 1 bedroom apartment.  The patient is approved for home care / personal care home health care (HHC) - level 2 personal care services, per 15 minutes 50 hours/week. The request is for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in) that was denied by the insurer, leading to an external review. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as severely impaired. The patient reportedly requires maximal assistance to total dependence for performing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. However, only limited assistance is needed for dressing. The patient is otherwise at the supervision level or independent for bathing, personal hygiene, eating, bed mobility, locomotion, toilet transfer/use and ambulation. The patient does not use an assistive device for ambulation (e.g., cane or walker). The patient is reportedly infrequently bladder and bowel incontinent. There has been no change in the patient's ability to perform activities of daily living (ADLs) or reported falls over the prior 90 days.  The patient's functional ability has actually improved when compared to the previous UAS report.

The letter from the patient's treating physician documenting the patient's clinical condition that causes "wandering during the day and night, the patient leaves home and often cannot find their way home" was reviewed.  The provider also notes the patient "requires constant supervision and assistance.  Patient can't be left alone for their safety."  The reviewer would agree, the patient may benefit from additional monitoring for safety; particularly due to the patient's reported progressive cognitive declined and propensity for wandering.  However, personal care services (PCS) hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no one else is available to provide assistance; not primarily for safety monitoring (e.g., dementia, wandering, falls risk).  Based on the documents reviewed, the patient's functional needs are appropriately provided and maintained by the approved home care / personal care HHC - level 2 personal care services, per 15 minutes 50 hours/week.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in) is not substantiated.