Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Parkinson's disease and status post transient ischemic attack (TIA)
Treatment: Increase Home/Personal Care Level 2 Live -In Services to 24 Hours per Day (Split Shift)
The insurer denied Increase Home/Personal Care Level 2 Live -In Services to 24 Hours per Day (Split Shift).
The denial is overturned.

The patient is an elderly female with history of general debility due to dementia, Parkinson's disease and status post transient ischemic attack (TIA). The request is for Personal Care Assistance through Home Health Care (Level 2) to be increased from 24 hours per day, live-in, 7 days per week to 168 hours per week (24 hours per day, split shift, 7 days per week) based on Uniform Assessment System (UAS) of 2 months ago. The health plan denied the request because the patient's functionality has changed minimally, with no major changes to her activities of daily living (ADLs) and the fact that the patient is already receiving 24 hours per day, live-in, personal care assistance (PCA). The additional hours requested are because of the patient's chronic medical conditions, and to help with her activities of daily living as she requires extensive assistance with most activities of daily living. A review of the records shows that the patient has multiple chronic medical conditions including dementia, Parkinson's disease, hypertension, hyperparathyroidism, urinary tract infection (UTI), psychosis, depression, history of transient ischemic attack, diabetes mellitus, gastric cancer, and history of abnormal gait/mobility with increased risk of falls. Uniform Assessment System - New York (UAS-NY) evaluation of 2 months ago shows that the patient is moderately cognitively impaired, with decisions consistently poor to unsafe at all times, requiring extensive assistance with phone use, bed mobility, eating, maximal assistance for transportation, bathing, personal hygiene, upper/lower body dressing, managing medications, toilet transfer, and totally dependent for meal preparation, housework, managing finances, shopping, locomotion, and toilet use. The patient lives alone in a one-bedroom apartment.

The requested health service is medically necessary.

The requested increase for Personal Care Assistance through Home Health Care (Level 2) from 24 hours per day, live-in, 7 days per week to 168 hours per week (24 hours per day, split shift, 7 days per week) is medically necessary because the patient is moderately cognitively impaired, with decisions consistently poor to unsafe at all times, requiring extensive assistance with phone use, bed mobility, eating, maximal assistance for transportation, bathing, personal hygiene, upper/lower body dressing, managing medications, toilet transfer, and totally dependent for meal preparation, housework, managing finances, shopping, locomotion, and toilet use. The reason for denial by the health plan as stated in the clinical information above, does not align with the patient's disability features as stated in the most recent Uniform Assessment System. Therefore, the 168 hours per week (24 hours per day, split shift, 7 days per week) as requested should be approved.