Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: HHC- level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in).
The insurer denied HHC- level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in).
The determination is overturned.

This a female patient with a medical history notable for dementia, Parkinson's disease, and incontinence. The patient is approved for 49 hours per week of level 2 personal care services. The patient and her care team requested an increase to 24 hours per day (live-in), and this request was denied by the health plan.
A letter of support was provided for this appeal. The letter states that the patient recently had worsening of her symptoms due to the new onset of hydrocephalus which required hospitalization. She cannot transfer or toilet without assistance. She therefore would be left alone for 17 hours per day without any help with incontinence care or other functional needs under her current allotment of hours. The letter states that her family is no longer able to provide the same level of support.
She currently resides in a skilled nursing facility and progress notes were provided for review. The note states that "due to Parkinson's disease and dementia, needs help around the clock with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs)."
A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted at a skilled nursing facility from which she had an anticipated discharge date. The patient was oriented to person and inconsistently to place. Her cognition was moderately impaired. She requires total dependence for meals, housework, finances, and shopping. She requires maximal assistance for medications and transportation. For her ADLs, she requires maximal assistance for bathing and toilet use. She requires extensive assistance for hygiene, dressing, and toilet transfer. She requires limited assistance for walking, locomotion, bed mobility, and eating. She is occasionally incontinent of urine and uses pullups. She has had no new falls since being admitted to the skilled nursing facility. Compared with a prior UAS, she showed a decline in cognition and functional status. At issue is the medical necessity of HHC- level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in).

The requested health service of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in) is medically necessary for this patient.
The patient has functional needs that require hands-on assistance with all IADLs and ADLs. She also has dementia and cannot direct her own care. Her personal care needs can be expected to be continuous and unscheduled, and thus 24-hour care is appropriate. Her current treating physician also attested to this in the most recent progress note. Failure to provide adequately for her functional needs could result in falls and/or infection due to a lack of proper toileting and incontinence care. If the family is no longer able to provide this support informally, then it is medically necessary for the plan to provide for this need.