Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Other - Dementia.
Treatment:  Increase in Personal Care Worker (PCW) Services to 7days per week, 24 hours per day, continuous care by more than 1 person, 168 hours per week.

The health plan denied increase in Personal Care Worker (PCW) Services to 7days per week, 24 hours per day, continuous care by more than 1 person, 168 hours per week.  The determination is Partially Overturned.

The patient is a female with medical history notable for dementia and ambulatory dysfunction. The patient is approved for 9 hours per day, 7 days per week (63 hours per week) of personal care worker services. The patient and her care team requested an increase to 24 hours per day continuous care by more than one person, 7 days per week (168 hours per week), and this request was denied by the health plan.

The patient's physician provided a letter of medical necessity for this appeal. The patient was hospitalized for urinary retention and fecal impaction. She was discharged but subsequently readmitted a few hours later with generalized weakness. She has shown overall functional deterioration and relies on others for most activities of daily living (ADL). She is unable to shower, ambulate, or change her diaper without assistance from a caregiver. She lives alone and does not have any informal assistance.

The patient's son provided a letter of support for this appeal which was reviewed in detail as part of this review.

A Uniform Assessment System (UAS) was completed. The assessment was conducted in-person. The patient lives alone in her apartment. She was alert and oriented to person and place only; she was noted to be forgetful with periods of confusion. A Mini Mental Status Examination score was 21/30, consistent with mild to moderate cognitive impairment. For her instrumental activities of daily living (IADL), she requires total dependence for housework. She requires maximal assistance for meal preparation, shopping, and transportation. She requires extensive assistance with medications and finances. For her ADL's, she requires maximal assistance for bathing, dressing, and toilet use. She requires extensive assistance for hygiene, walking, locomotion, toilet transfer, and bed mobility. She requires limited assistance for eating. The patient was observed walking and transferring with weight bearing assistance from her personal care worker. She is frequently incontinent of urine and stool with some control present. Compared to a previous assessment, she showed a slight decline in functional status.

The health plan's determination of medical necessity is overturned in part.

The requested health service/treatment of increase in Personal Care Worker (PCW) Services to 7 days per week, 24 hours per day, continuous care by more than 1 person, 168 hours per week has not been demonstrated to be medically necessary for this patient.

The patient has had a decline in functional status. She does require personal care assistance for nearly all ADL's and IADL's. However, continuous care by more than 1 person is only deemed medically necessary if a patient has demonstrated personal care needs which are expected to be continuous throughout the day and night and which could not be satisfied at a lower level of care. These services are indicated for instances such as turning and repositioning to address pressure wounds. There is no documented medical necessity for the patient to have continuous 24-hour personal care. Although she may require more assistance at home than she currently receives, there is no clear medical necessity demonstrated for the request of 24-hour continuous care. This patient would be appropriate for 24-hour per day live-in personal care (91 hours per week).