202207-151875
2022
Healthfirst Inc.
Medicaid
Mental Health
Home Health Care
Medical necessity
Overturned
Case Summary
Diagnosis: Alzheimer's dementia
Treatment: 7 days per week, 24 hours per day (live-in) personal care assistance services
The insurer denied coverage for 7 days per week, 24 hours per day (live-in) personal care assistance services.
The denial is overturned.
This is a patient with chronic medical problems including Alzheimer's dementia. She lives with her daughter and granddaughter. The daughter works and cannot continue to provide care. The grandchildren are not involved. She is currently approved for personal care assistance (PCA) services 68 hours/week. Currently under review is the request for increase PCA services 7 days/week, 24 hours/day (live-in).
The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as severely impaired. She requires maximal assistance for bathing, personal hygiene, dressing, walking and toilet use. She is frequently bladder and bowel incontinent. This has become more severe as her dementia progresses. Extensive assistance is needed for eating, toilet transfers and walking. A letter by her care manager noted that there has been significant deterioration. She has been found half of her body in the bed and unable to pull herself back into position. Also, noted that pullups need changing at least every 2 hours. The patient uses diuretics which increases urination. She has also had fungal infections in her groin area. The UAS notes the daughter was instructed in the importance of repositioning every 2 hours and change incontinence supplies on time. The patient has severe cognitive deficits and significant functional impairments, which continue to decline and support the medical necessity of increasing PCA services to 7 days per week, 24 hours per day (live-in)
Her condition and functional needs are at a level or unpredictable, as to require the requested 24 hours per day (live-in) PCA services.
The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).
From a physical medicine and rehabilitation perspective, the requested PCA service 7 days/week, 24 hours/day (live-in) is medically necessary.
The insurer's denial of coverage for 7 days per week, 24 hours per day (live-in) personal care assistance services is overturned. Medical Necessity is substantiated.