Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/ Neuromuscular Disorder- Other- Dementia
Treatment: Home Health Care-personal care worker
The health plan denied the requested service of 24 hours per day; continuous care by more than 1 person; 168 hours per week as not medically necessary. The reviewer has overturned the health plan's determination in part. 

This is a case review for a patient with medical history notable for dementia. The patient was approved for 10 hours per day, 7 days per week for a total of 70 hours per week of personal care worker services. The patient and her care team requested an increase to 24-Hour per day split shift care (continuous care by more than one person), 7 days per week. This request was partially denied by the health plan, who did approve and increase it to 11 hours per day, 7 days per week. The denial of continuous 24-hour care is the subject under review.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has ischemic heart disease and dementia. She has an unsteady gait and has had multiple falls with resulting injuries. She is incontinent of both urine and feces. She is disoriented and requires assistance with directing and completing activities of daily living. She is mostly bedridden. Her daughter does provide care for her mother, but due to a spinal condition she cannot lift or reposition her mother as needed and cannot provide for her personal care needs. The physician recommends 24-hour care at home.
A Uniform Assessment System (UAS) was completed. The assessment was conducted in person. The patient lives in the first floor living room of a private home. She was alert and oriented to person only with intermittent confusion. For her instrumental activities of daily living, she requires maximal assistance or total dependence for all. For her activities of daily living, she requires maximal assistance for bathing, hygiene, dressing, toilet transfer, and toilet use. She requires extensive assistance for walking, locomotion, bed mobility, and eating. She is frequently incontinent of both urine and stool. There was no fall in the previous 90 days. There was no pressure ulcer present.
A second assessment was performed where the patient's cognition had deteriorated, and she was now severely impaired. She no longer recognized her daughter. From a functional standpoint, the patient showed a decline and now requires maximal assistance or total dependence for all activities of daily living. She now requires total dependence for toilet use. There was no fall in the previous 90 days. There was no pressure ulcer present.

The requested service of increase in personal care worker services to 24-Hour per day continuous care by more than one person has not been clearly demonstrated to be medically necessary for the patient. However, 24-hour per day live-in personal care is medically necessary for the patient. The patient's care needs are extensive, as she requires maximal assistance or total dependence for all activities of daily living. She has advanced dementia and cannot direct her own care. She is also incontinent of both urine and stool and requires personal care assistance with directing and managing incontinence care episodes. Her care needs are, by definition, continuous and unscheduled throughout the day and occasionally at night as well. She requires 24-hour care. However, there is insufficient documentation that she requires continuous 24-hour care by more than one person. There were no nighttime logs provided for review. There is insufficient documentation that a live-in-personal care aide would not be able to receive adequate rest at night. The patient does not have any evidence of pressure ulcer which would require frequent turning and repositioning throughout the night. Therefore, the requested service of 24-hour per day continuous care by more than one person has not been clearly demonstrated to be medically necessary for the patient.