Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Central Nervous System/ Neuromuscular Disorder/Alzheimer's Disease/	Alzheimer's, Cerebral amyloid angiopathy and dementia.
Treatment: Home Health Care/Personal Aid Care 8 hours per day -7 days per week total of 56 hours per week
The health plan denied Home Health Care/Personal Aid Care 8 hours per day -7 days per week total of 56 hours per week as not medically necessary. The health plan's determination is overturned, in part.

This is a case review for a female with a medical history notable for Alzheimer's dementia.

The patient's physician requested an increase in home health aide hours because it is unsafe for her to be alone for prolonged periods of time. She does not have any reliable informal support. She has severe dementia and has been lost multiple times in the community when aid was not present. The patient's Neurologist states that the patient's Alzheimer's disease is severe. Therefore, her ability to handle instructions or daily tasks has begun to be disrupted. The physician requested constant supervision because of a history of wandering behaviors. They recommend increasing the home health aide hours.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person with the patient's daughter present. The patient lives in a house with her spouse and daughter. The patient's cognition was moderately impaired; she was disoriented at times, very forgetful, and required constant supervision. Her recall was 1/3 at 5 minutes. For her instrumental activities of daily living (IADL), she requires total dependence for meal preparation, housework, and shopping. She requires maximum assistance for medications and transportation. For her actiities of daily living (ADL), she requires extensive assistance for bathing. She requires limited assistance for all other activities, with the exception of eating for which she is independent. She requires contact support with activities such as dressing and hygiene, and requires some weight bearing assistance with bathing. She requires caregiver assistance for toileting. A task tool recommended 5 hours per day, or 35 hours per week to address her personal care needs. Compared to a prior UAS, the patient showed a decline in cognitive and functional status. 

At issue is the medical necessity for Personal Aid Care 8 hours per day -7 days per week total of 56 hours per week.

The health plan's determination of medical necessity is overturned in part; the patient's personal care aide hours should be increased to 5 hours per day, 7 days per week (35 hours per week).

The requested health service of Personal Aid Care 8 hours per day -7 days per week total of 56 hours per week has not been demonstrated to be medically necessary for this patient.

The patient has functional limitations primarily as a result of worsening dementia. She does not have any reliable informal assistance in the home secondary to her family members' own medical problems. She requires assistance primarily with instrumental activities of daily living, with some light contact assistance for ADL. A task tool recommended 5 hours per day, 7 days per week to address her personal care needs. The health plan should accommodate this recommendation by increasing the patient's hours accordingly.
There is insufficient evidence to demonstrate the medical necessity of an increase to 8 hours per day, 7 days per week as requested by the patient's family. The letters outline the need for constant supervision in the setting of dementia, but supervision and safety monitoring is not an allowable personal care task in the absence of performing another personal care function.