Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Personal Care Aide (PCA) Level 2: 8 hours per day - 7 day(s) per week - for a total of 56 hours per week.
The insurer denied: Personal Care Aide (PCA) Level 2: 8 hours per day - 7 day(s) per week - for a total of 56 hours per week.
The denial is overturned in part.

The patient is a male with medical history notable for dementia, diabetes, congestive heart failure, multiple myeloma, mitral valve insufficiency, and hypertension. The patient is approved for 4 hours per day, 5 days per week (20 hours per week) of level 2 personal care services. The patient's care team requested an increase to 8 hours per day, 7 days per week (a total of 56 hours per week).
A letter of support for this appeal was provided by the patient's treating physician. The letter states that "he is struggling with his activities of daily living (ADLs). And it is my medical opinion that more hours with Home Health Aide (HHA) would help him significantly." There were no further details provided on how additional aide hours would provide for unmet personal care needs.

A Uniform Assessment System (UAS) was completed and was available for review. The review describes the patient's cognition as minimally impaired. He is alert and oriented times two, and five minute recall is 0/3. He is unable to verbalize an emergency plan. From a functional standpoint, he requires total dependence for meal preparation, housework, and finances. He requires maximal assistance for managing medications. For his activities of daily living (ADLs), he requires maximal assistance for bathing, and dressing lower body. He requires extensive assistance for hygiene, dressing upper body, walking, toilet transfer, toilet use, and bed mobility. He requires total dependence for locomotion. ADL status was declining, and self-sufficiency has deteriorated. He is occasionally incontinent of urine (less than daily) and is continent of stool. He wears pull-ups for incontinence episodes. A task tool associated with the assessment recommended 30 hours per week (5 days per week) for his personal care needs. Compared with a prior UAS, the patient shows a decline in several ADL's including locomotion, bathing, and dressing lower body. The task tool at that time also recommended 30 hours per week, spread over 5 days.

The requested health service/treatment of Personal Care Aide (PCA) Level 2: 8 hours per day - 7 day(s) per week - for a total of 56 hours per week has not been proven to be medically necessary for this patient, however an increase to 30 hours per week is necessary.
The patient has declining functional status and needs assistance with most ADL's and Instrumental activities of daily living (IADLs). Given his decline since the prior UAS, it is reasonable to expect that he would require additional hours. Furthermore, the tasking tool recommends 30 hours per week. This should be a minimum allotted to him. The patient's care team did not demonstrate any unmet personal care needs or medical necessity that would require 56 hours per week of personal care services. The most recent UAS is 6 months old at this time, so if there has been a functional change he may need to be reassessed. Given the information provided, the patient should be provided with 30 hours per week of personal care services as recommended by the task tool associated with the UAS.