Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week.
The insurer denied home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week.
The determination is overturned.

This is a female patient with a medical history notable for dementia, incontinence, COPD, and gait disturbance. The patient is approved for 44 hours per week of level 2 personal care services. The patient and her care team requested an increase to 84 hours per week, and this request was denied by the health plan.
A letter of support for this appeal was provided by the patient's cardiologist. The letter states that the patient is "required to have more attention to prevent falls as she is prone to falls and help with activities of daily living to improve the quality of life. She will need someone by her side supervising and taking care of her at all times and is hence advising 24-hour care."
A letter of support for this appeal was provided by the patient's granddaughter. The letter states that the patient lives with family members but they are not always present to assist as they work full-time.
The patient's daughter provided a letter of support for this appeal. The letter states that they are unable to provide the 24-hour care that the patient's physician requested due to her working a full-time job.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented to person and at times to place. She is able to verbalize simple needs but she is not able to direct her own care; cognition is moderately impaired with supervision required at all times. From a functional standpoint, she requires total dependence for meal preparation, housework, finances, phone use, and shopping. She requires maximal assistance for medications and stairs. For her activities of daily living (ADLs), she requires maximal assistance for bathing and dressing lower body. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, toilet use, and bed mobility. She is incontinent of urine with no control present and uses pull-ups and chux for incontinence care. A task tool associated with the assessment recommended 41.17 hours per week to address her personal care needs. Compared with a prior Uniform Assessment System (UAS), she demonstrated a decline across several ADLs. At issue is the medical necessity of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week.

The requested health service/treatment of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 84 hours per week is medically necessary for this patient.
The patient requires assistance with all Instrumental activities of daily living (IADLs) and ADLs. She requires assistance with toileting and changing her clothes and is fully incontinent of urine. She is not able to fully make her needs known. She cannot be left alone by herself to manage these personal needs. When patients have periodic, unscheduled personal care needs such as toileting and incontinence care, a task tool cannot reliably assess the true level of need for personal care hours. Personal care is not allowed simply for safety monitoring in a patient with dementia, but the increase in hours is medically necessary to allow the patient to have her personal care needs fulfilled.