Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia 

Treatment: Home Care / personal care HHC - level 2 personal care services for a total of 24 hours per day (live in).  

The insurer denied coverage for home Care / personal care HHC - level 2 personal care services for a total of 24 hours per day (live in)

The denial is modified.

The patient is a male with progressive dementia with episodes of confusion, agitation, restlessness; PCP started Namenda and Exelon; psychiatrist started Seroquel (partial help, less agitated).  The insurer has denied coverage for the home Care / personal care HHC - level 2 personal care services for a total of 24 hours per day (live in). The patient has no real insight into his mental problem.  MRI show moderate white matter ischemic changes.  Assessment: progressive dementia, probably Alzheimer's disease; activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are impaired; needs assistance; home aide is necessary

Uniform Assessment System (UAS) includes the following:

-	Diagnoses:  coronary heart disease, hypertension, hypercholesterolemia, bladder cancer, leukemia, malignant neoplasm of skin, dementia, osteoarthritis, gout, history of (h/o) falling, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, gastroesophageal reflux disease (GERD), exocrine pancreatic insufficiency, cyst of pancreas, glaucoma,  hypomagnesemia

The patient has several medical conditions contributing to cognitive and functional impairment. He lives alone. The external appeal application includes a letter (appears to be the friend/designee submitting the external appeal) reporting that the patient's son lives in another country and grandson in another state. Both were visiting at the time of the UAS, so the patient had informal assistance at that time; but not usually. It was noted in the UAS that a friend pre-pours medications and provides reminders for medications, but the friend/designee's letter reported that the friend does not currently live near the patient and cannot provide this assistance. No other informal caregivers are identified. The patient is receiving PCS 35 hours per week, 5 hours per day. As per UAS and designee's letter the patient is alone the rest of the day and night. Request was made to increase PCS to 24 hours per day live-in, which was denied. An external appeal was requested.

The patient has physical impairments that limit his ability with some ADLs; but it is unclear if and to what extent his cognitive impairment affects his ADLs. The UAS reports most ADLs as independent or set up help; except bathing and lower body dressing requiring extensive assistance. The latter is most likely due to back and lower extremities pain. Cognitive impairment can affect the safety with which ADLs are performed. Set up help can be an important issue for a person with memory loss. For example, the patient needs a cane for ambulation. If he forgets to use the cane, his balance and stability when walking is impaired and he risks falling. Impaired memory, poor judgment and decreased safety awareness during ADLs increase risk of falls and household accidents. Providing supervision or cues when needed for safety during ADLs is part of the scope of care provided by personal care services. 

Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes 24 hours per day (live-in) is modified to approve Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes 12 hours per day, 7 days per week; 84 hours per week.

The health plan acted reasonably in part as live - in services are not medically necessary but an increase to 12 hours per day, 7 days per week; 84 hours per week is medically necessary

The insurer's denial of coverage for the requested Home Care / Personal Care HHC - Level 2 Personal Care Services for a total of 24 hours per day (live in) is modified.