Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease. 
Treatment: Home Care and Personal Care, Home Health Care (HHC) Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week. 

The health plan denied the Home Care and Personal Care, Home Health Care (HHC) Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week. 

The health plan's determination is overturned. 

The patient is a female with a medical history notable for Alzheimer's dementia, incontinence and coronary artery disease. The patient was approved for 25 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 partially denied; she was approved to increase to 32 hours per week. 

A letter of support for this appeal was provided by a patient advocate.  The letter states that the Uniform Assessment System (UAS) assessment was not conducted properly. They state that the assessment took only ten minutes and that they did not speak to the patient during the assessment. They feel that the information that is contained within the report is "inaccurate and unfair." The letter states that the patient has dementia and incontinence. She cannot move without assistance and needs help with toileting. The letter states that the patient lives with the letter writer's family who is helping with the patient's care, but that it is becoming too much for the family to handle. 

There were no letters provided by the patient's physician, nor were there any medical records provided for this review. 
The Uniform Assessment System (UAS) that was completed on was reviewed. The patient's cognition was found to be moderately impaired. She was alert and oriented to person only and she was unable to direct her own care. From a functional standpoint, she requires total dependence for housework and shopping. The patient requires maximal assistance for managing finances, medications, stairs and transportation. For her activities of daily living (ADL's), she requires maximal assistance for bathing, dressing lower body, walking and locomotion. She requires extensive assistance for hygiene, dressing upper body, toilet transfers and toilet use. She requires limited assistance for bed mobility and eating. The notes state that she is unable to direct her care and requires assistance for all ADL's and Instrumental activities of daily living (IADL's). She is frequently incontinent of urine and occasionally incontinent of stool. The patient wears liners and pull ups to manage incontinence. Compared to a prior assessment the patient's functional status did not change significantly. A task tool associated with the most recent assessment recommended 29.5 hours per week for her personal care needs, which was actually a decrease from the 44.3 hours recommended on the previous assessment. Of note, the task tool states that the patient is alert and oriented times three with periods of forgetfulness, which is contradictory to the UAS report. 

The patient has a diagnosis of Alzheimer's dementia and has urinary incontinence. Her assessment recommendations were for a decrease in personal care time, which is not likely an accurate assessment. Dementia tends to be progressive and worsens over time, and it would only be expected that her level of need would increase. The assessment states that she is only oriented to person and cannot direct her own care. It would not be reasonable to expect her to complete all of her personal care tasks with less than 5 hours per day of assistance. Dementia can be particularly challenging because patients cannot make their own care needs known. She has incontinence and will need prompt attention to soiled diapers to prevent skin breakdown and or infection. The patient's family has been assisting with care, and if they are unable to continue to do so, it is medically necessary to provide for her functional needs.