Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia
Treatment: Increase Home Care Personal Care HHC Level II Personal Care Services, per 15 Minutes, to 24 Hour(s) per Day (Live-In)
The insurer denied the Increase Home Care Personal Care HHC Level II Personal Care Services, per 15 Minutes, to 24 Hour(s) per Day (Live-In).
The denial is overturned. 

This patient is a female with Alzheimer's dementia.  The patient is appealing denial of level II Personal Care Services, increase to 24 hours per day (live in) from approved 56 hours per week.  

Assessment performed shows moderately impaired cognitive skills and functional status:  total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, and phone use; extensive assistance with bathing, dressing and  toilet use; limited assistance with personal hygiene, walking, locomotion, toilet transfer, and eating; and supervision with bed mobility.  Compared to assessment performed a few months prior, there has been a decline in ability to perform meal preparation, managing finances, shopping, personal hygiene, dressing, walking, toileting, bed transfer and eating.  

Appeal letter from the agency who has been providing services for the patient states the patient has dementia which results in her wandering and not remembering to take medications or eat.  She is noted to have had a fall in her apartment.  Appeal letter from the granddaughter states the patient has rapidly accelerating Alzheimer's disease.  It states the patient wanders, and doesn't remember to bathe, dress, or eat.  It states the patient is not oriented to time and sometimes double doses medications.  She uses the stove, forgets and walks away.  It states the patient had coronavirus (COVID) after which her overall health decompensated.  The patient has further weakness, malaise, and dizziness.  An appeal letter from the patient's provider states the patient has advancing dementia with a dramatic decline in her cognition since most recent visit.  She has an unsteady gait.  She has visual impairment affecting activities of daily living.  The patient is incontinent and needs reminders and assistance with diaper changes.  An appeal letter from the building superintendent states the patient has been wandering, lost and disoriented,  Also, notes the patient has fallen multiple tines in the building.  Appeal letter from the daughter states the patient's Alzheimer's has progressed affecting her ability to perform activities of daily living.  It states the patient has a gait problem and is high risk for falls.  Appeal letter a second provider states the patient has rapidly worsening Alzheimer's.  It states the patient is noncompliant with her medications.  It states the patient needs prompting from an aid for activities of daily living and to eat.

Yes, the proposed Increase Home Care Personal Care HHC Level II Personal Care Services, per 15 Minutes, to 24 Hour(s) per Day (Live-In) is medically necessary.

Medically necessary services are those which are:
-safe 
-effective
-generally accepted national standard of medical practice 
-not provided primarily for convenience of the patient or the practitioner 
-the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice.

Level II personal care service is indicated for individuals that need assistance with housekeeping, cleaning, meal preparation, grocery shopping, and laundry as well as assistance with personal needs, including bathing, dressing, grooming, toileting, walking, feeding, assisting with administering medications, preparing meals with special diets, and routine skin care.  

This patient was approved for 56 personal care service (PCS) hours per week.  The patient lives alone and has progressive Alzheimer's disease.  She also has a visual impairment and unsteady gait affecting functional status.  The assessments show a decline in the patient's functional status over several months.  The patient needs assistance meal preparation, housework, managing finances, shopping, managing medications, phone use, bathing, dressing toileting, personal hygiene, walking, locomotion, toilet transfer, and eating.  An appeal letters show the patient's condition is rapidly deteriorating.  Other than bed mobility, she needs assistance with activities of daily living and instrumental activities of daily living.  She has shown to be unsafe due to her impaired cognition.  She needs reminders for medication management to avoid over or under dosage and reminders for diaper changes due to incontinence.  In addition, she has been having increasing falls.  Based on the progression of this patient's Alzheimer's dementia, the currently approved 56 personal care service hours per week are insufficient to meet the around the clock needs for assistance.  The requested Level II personal care service increase to 24 hours per day is appropriate for this patient.