Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (live in)
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (live in).
The determination is overturned.

The patient has a past medical history of dementia, chronic obstructive pulmonary disease (COPD), osteoarthritis, hypertension, anemia, hypothyroidism, bladder incontinence, and bowel incontinence who had been assigned 28 hours/week of Consumer Directed Personal Assistance Program (CDPAP) services based on an assessment performed assessing the patient at total assistance with meal preparation and ordinary housework while maximum assistance with the task of managing finances. With the tasks of managing medication, phone use, stairs, shopping, transportation, and bathing the patient was assessed at extensive assistance while limited assistance with the tasks of dressing upper/lower body. The patient was assessed as independent with the tasks of personal hygiene, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. Notes from assessment stated the assessment was the patient's first assessment. The tasking tool calculated 25.25 hours of activities of daily living (ADLs) / Instrumental activities of daily living (IADLs) assistance needs per week.
The patient presented to the emergency room with weakness and later again following a fall at home and was noted to be coronavirus disease (COVID) positive. The patient underwent a patient review instrument (PRI) evaluation noting the patient required continual help with eating, needed constant one-to-one supervision and/or constant physical assistance with mobility, required intermittent supervision and/or physical assistance for transferring, was incontinent of bowel and/or bladder, and the patient had a history of falls and history of wandering. There was a request to increase CDPAP/personal care assistant (PCA) services and the patient underwent an assessment tool via Zoom assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, and shopping while maximum assistance with the task of transportation. With the tasks of managing finances, managing medication, stairs, bathing, and dressing lower body the patient was assessed at extensive assistance while limited assistance with the tasks of phone use and dressing upper body. The patient was assessed at supervision with the tasks of walking, locomotion, transfer toilet, toilet use, and eating while independent with task of bed mobility. Notes from the assessment indicated the patient lived with her daughter and granddaughter and had a history of wandering, and attended social daycare 2 days/week.
The patient was admitted to the hospital for a urinary tract infection. Notes from the discharge summary stated the family was trying to get the patient into a short-term rehabilitation (rehab) facility and the patient had been declining at home with difficulty ambulating. The patient was started on Aricept. Notes stated discharge planning to rehab planned as family was looking into short-term placement. The insurer sent an initial adverse determination denial notice partially denying the request to increase CDPAP services increasing services to 35 hours a week. The denial stated the assessment showed no change in activities of daily living within the last 90 days and no change in overall self-sufficiency. The report from care center stated the patient was able to dress upper and lower body, perform personal hygiene and grooming on her own. The denial also stated there had been a change in the patient's clinical condition and changes in her social circumstances. Lastly, the denial stated safety monitoring was a not part of the total personal care service hours for personal care received. The insurer also sent a final adverse determination denial notice denying request to increase CDPAP/PCA services stating the personal-care hours were currently authorized in the amount, duration, and scope necessary to meet the patient's personal care needs. The denial decision was appealed stating the patient required a.m./p.m. medication reminders and overnight bathroom assistance.
At issue is the medical necessity of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (live in).

Yes, the services are medically necessary. There is documentation that the patient has progressive dementia as noted in her hospital admission with bowel and bladder incontinence. The patient's PRI indicated the patient required continual help with eating and one-to-one supervision and/or constant physical assistance with mobility. The patient's Zoom assessment underestimated the patient's assistance needs with eating and mobility. The patient has incontinence of bowel and bladder and requires greater than supervision assistance with incontinence care. The patient has medications that are dosed twice daily and the patient needs reminders not just in the morning hours but also in the evening hours to maintain her health. The patient requires assistance with walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. Tool based assessment should not have been used to calculate the patient's PCA hours as she has 24 hour care needs. The requested increase in CDPAP/PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP/PCA services 24 hours/day, live-in, 7 days/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.