Diagnosis: Dementia
Treatment; Home health care
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services: 55 Hours per Week. The health plan's determination is overturned.

The patient is a female with past medical history of dementia, hypertension, urinary incontinence, osteoporosis, chronic obstructive pulmonary disease (COPD), aortic stenosis, and osteoarthritis.

Home Care / Personal Care HHC - Level 2 Personal Care Services: 55 Hours per Week are medically necessary for this patient.
There is documentation from the assessment that the patient has had increased assistance needs with tasks of dressing lower body, transfer toilet, toilet use, and bed mobility. Despite this change there was no significant increase in the amount of hours per week provided to the patient for Personal Care Aid (PCA) services. The patient has no informal help other than her son who is noted to work as a professor and is unable to provide continuous care outside of the hours of currently assigned PCA services. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs when the patient has no informal help. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 55 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.