Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease
Treatment: Home Health Care
The health plan denied the requested increase in home health care hours. 
The health plan's determination is overturned.

The patient is a female with a history of coronary artery disease, osteoarthritis, chronic pain, ambulatory dysfunction and Alzheimer's dementia.

With her underlying medical conditions including cognitive dysfunction and chronic pain leading to ambulatory dysfunction, she has had a personal care assistant (PCA) for the last several years. Recently, according to the record review, her condition has worsened, and her needs have increased. She has historically had PCA services for 42 hours a week, 6 hours/day, 7 days/week. The request is to have this doubled to 12 hours/day, 7 days/week for a total of 84 hours. This request was declined as being not medically necessary by the patient's service plan.

Review of records demonstrates that the patient's condition has notably worsened over the 10-month interval between assessments. Increased cognitive needs have appeared. Decreased communication skills including expression and comprehension of language has been affected. There are increased physical needs with decreased mobility and ambulatory ability with increased fall risk. Despite these changes being documented in notation from the patient's physicians as well as uniform assessment systems, the care plan commented that no significant changes in the condition had been noted in the interval between assessments.

At issue is the medical necessity of the requested increase in PCA hours.

The health plan's determination of medical necessity is overturned, in whole.

With the patient's outlined medical conditions as provided in the records including medical diagnoses of Alzheimer's dementia, coronary artery disease, osteoarthritis, ambulatory dysfunction and dizziness, the utility of a personal care aide is clearly appropriate. This is supported by the presence of a PCA in the home for several years prior to this request.

As it relates to the request for increased services, 12 hours/day, 7 days/week, this request too is appropriate. Review of the Uniform Assessment System evaluations provided clearly show a decline in overall status and function as it relates to daily care needs. The patient has demonstrated worsening communication skills, both in expression and in understanding. She continues with significant orthopedic limitations requiring assistance with bathing, hygiene and dressing. As it relates to toileting, she needs assistance with toileting. Description of limitations shows worsened mobility with transferring from the toilet including utilizing the sink as a support. This is clearly unsafe and places the patient at an increased risk of fall with subsequent increased risk in morbidity and mortality. The presence of a PCA to help assist in this would lower this risk and aid the patient in appropriate completion of these tasks. As it relates to the hours allotted, the original plan lists services from 9 AM to 3 PM. The patient likely needs to use the toilet at other times of the day beyond those covered.

Therefore, it is appropriate and medically necessary for the patient to have the services requested. The presence of a PCA for 12 hours/day, 7 days/week for a total of 84 hours/week is medically appropriate.