Diagnosis: Central Nervous System/Neuromuscular Disorder/Other/Dementia
Treatment: Home Health Care-Personal Care Aide
The health plan denied the requested increase in personal care assistance hours.
The health plan's determination is overturned.

The patient is a female with a past medical history of severe dementia, urinary incontinence, bowel incontinence, chronic low back pain, gastroesophageal reflux disease (GERD), hypertension, anxiety, insomnia, and atrial fibrillation who had been assigned personal care assistance (PCA) services 7 hours/day, 7 days/week to total 49 hours per week. The patient was assessed at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of phone use, stairs, transportation, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility while limited assistance with tasks of eating. The family reported the patient was unable to go to the bathroom on her own and refused to wear undergarments and thus there were daily accidents of bladder and bowel. The family also reported sundowning with the patient's daughter having to waken every hour to check on the patient. The family was letting the patient go down the stairs on her buttocks for safety when the patient was trying to go downstairs even though she had everything she needed in her own apartment.

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

Yes. The patient has progressive dementia with documented decline in physical and mental functioning. The patient requires assistance with all ADLs/Instrumental activities of daily living (IADLs). The patient had 24-hour care needs and therefore the assessment tool should not have been utilized to calculate PCA hours. The patient had unscheduled and unpredictable care needs over a continuum of time and the insurer did not document a plan to address these unscheduled and unpredictable care needs. The patient no longer has the level of informal support as previous, as her daughter cannot provide care due to her own medical illnesses. The patient requires turning and positioning every two hours. An aide would not obtain at least 5 hours of uninterrupted sleep and therefore would require split- shift aide services. Increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Considering the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.