Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypertension, hyperlipidemia, chronic pain, abnormal gait, muscle weakness, depressive disorder, urinary incontinence, right hip fracture, dizziness, and history of falls
Treatment: Home Care/Personal Care Level II Personal Care Services 168 Hours Per Week
The insurer denied the Home Care/Personal Care Level II Personal Care Services 168 Hours Per Week.
The denial is overturned. 

This patient is a female with conditions including dementia, hypertension, hyperlipidemia, chronic pain, abnormal gait, muscle weakness, depressive disorder, urinary incontinence, right hip fracture, dizziness, and history of falls.  This is an appeal for denial of Level II personal care services (PCS) at 168 hours per week.  She was approved for 70 hours per week.  

The patient lives with her daughter.  Uniform Assessment System (UAS) evaluation performed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing finances and medications, phone use, stairs, and transportation; extensive assistance with bathing, personal hygiene, dressing, walking, locomotion, and toileting; and limited assistance with bed mobility and eating.  Hours of physical activity are one to two per day.  She is occasionally incontinent of bladder.  She has equipment including a hospital bed, walker, and wheelchair.  She is able to ambulate short distances with walker and uses wheelchair for longer distances.  Uniform Assessment System (UAS) evaluation performed three months after previous assessment shows decline in ability to perform activities of daily living (ADLs) to now require maximal assistance with bathing, lower body dressing, and locomotion.  She has received physical therapy (PT) and occupational therapy (OT).  

There are several progress reports, an advocacy report, and appeal documents that include letters from the patient's daughter, nurse practitioner (NP) and medical doctor (MD).  These appeal documents state the patient is unable to direct her care due to advanced dementia and requires prompting and cueing.  She has limited mobility and needs supervision at all times.  Twenty-four hour supervision and assistance is recommended for activities of daily living (ADLs).  Overnight logs show the patient routinely trying to get out of the bed at various times during the night to use the bathroom and for diaper change.

Yes, the proposed treatment is medically necessary.

Medically necessary services are those which are: 1) safe 2) effective 3) generally accepted national standard of medical practice 4) not provided primarily for convenience of the patient or the practitioner 5) 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 standards of medical practice.

This patient has multiple chronic conditions including advanced dementia.  She is unable to direct her care and requires prompting.  She is status post a fall that resulted in a hip fracture.  The requested personal care services (PCS) at 168 hours per day were denied.  She has been approved for 56 PCS hours per week.  

Uniform assessment system (UAS) evaluations performed show the patient requires assistance with all activities of daily living (ADLs)/instrumental activities of daily living (IADLs) with an inability to perform bathing, lower body dressing, and locomotion during the three-month interval between evaluations.  The appeal documents provided are consistent in reporting the patient as having advanced dementia and limited mobility.  She is incontinent of urine and overnight logs show frequent unscheduled assistance with transfers and ambulation for toileting and diaper change.  This patient has significant cognitive and functional limitations necessitating assistance with all ADLs/IADLs.  She has continuous needs that cannot be met with the approved personal assistance services at 70 hours per week.  The proposed increase in personal care services (PCS) to a 168 hours per week is medically necessary to meet this patient's needs.