Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia with Lewy Bodies, Wandering
Treatment: Home Care / Personal Care, home health care (HHC) - Level 2 Personal Care Services, per 15 Minutes; 84 Hour(s) per Week
The insurer denied the request for Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes; 84 Hour(s) per Week.
The health plan's determination is overturned.

The patient is a female with history of Lewy body dementia, low back pain, osteoarthritis, hypertension, normal pressure hydrocephalus, ataxia, urinary and bowel incontinence, and major depressive disorder. She was assigned personal care assistant (PCA) services at 35 hours/week. The patient's psychiatrist provided a letter stating the patient had generalized anxiety disorder and major neurocognitive disorder and had Alzheimer's dementia. The provider noted the patient required significant assistance with activities of daily living and that it was unsafe for the patient to be left alone for significant periods of time. The patient's neurologist provided a letter stating that the patient had difficulty with performing her activities of daily living (ADL's) and required assistance.

The patient's primary care physician (or provider) (PCP) provided a letter stating that the patient had poor cognition and secondary dementia and had to be under supervision 24 hours/day because she was a danger to herself and others. The letter also stated the patient had difficulties walking because of ataxia and needed assistance with walking, bathing, and grooming. The PCP letter also stated the patient had urinary incontinence and needed to be changed frequently and the patient lived alone and had no informal support to provide the patient with assistance to meet her personal care needs on a regular basis. 

There was an assessment performed assessing the patient at total assistance with the task of ordinary housework while she was maximum assistance with the tasks of meal preparation and managing finances. With the tasks of managing medication, shopping, and bathing the patient was assessed at extensive assistance while she was limited assistance with the tasks of phone use, stairs, personal hygiene, dressing upper/lower body, toilet transfers , and toilet use. The patient was assessed at supervision with the tasks of walking, locomotion, and eating while she was independent with the task of bed mobility. Notes from the assessment stated the patient lived alone, that she was moderately cognitively impaired, had episodes of wandering, used a cane indoors and a walker outdoors, and her sibling was her informal helper. The tasking tool estimated 30.08 hours/week.

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes; 84 Hour(s) per Week is medically necessary. There is documentation of worsening cognitive and physical functioning. The patient's medical provider recommended an increase in PCA services due to patient's worsening medical conditions and cognitive functioning. The patient required limited assistance with toilet transfers and extensive assistance with toilet use based on the assessment tool and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient would need assistance outside of the hours that she does not have informal help.

The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADL's and Instrumental activities of daily living (IADL's). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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.