Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease, Parkinson's Disease.

Treatment: Increase in consumer-directed personal assistance services (CDPAS) to 7 days per week, 24 hours per day - split shift.

The insurer denied coverage for an increase in consumer-directed personal assistance services (CDPAS) to 7 days per week, 24 hours per day - split shift.

The denial is overturned.

This is a patient who has a history of Alzheimer's disease, osteoporosis, cancer, Parkinson's, and chronic insomnia. The patient has greatly deteriorated mentally and needs help in all of their activities of daily living (ADLs) and is at a mild increased risk of falls. An increase in consumer-directed personal assistance services (CDPAS) to 7 days per week, 24 hours per day - split shift is requested and is the topic of this review.

In the Uniform Assessment System NY (UAS), the patient's cognition is severely impaired as the patient is unable to activate the Personal Emergency Response System (PERS) and was able to recall 0/3 words after 5 minutes during the assessment. Instrumental Activities of Daily Living (IADLs), meal preparation, housework, managing finances, shopping, phone, and managing medication use were dependent. Bathing, dressing lower body, walking, locomotion, transferring toilet, and toilet use were maximal assistance.  Personal hygiene, dressing the upper body, bed mobility, and eating are all extensive assistance.  The patient is completely incontinent of bladder and bowel.  The nighttime logs indicate the patient is up frequently and has multiple needs for diaper changes due to bowel incontinence overnight. The patient is alert and oriented times zero and is not able to make decisions for themselves nor provide consent. The patient is unable to call 911 is dependent on their ADLs and requires assistance 24 hours a day. Thus, the 7 days per week, 24 hours per day - split shift of CDPAS assistance should be approved.

"According to the 2021 Alzheimer's Disease Facts and Figures,1 the number of individuals with Alzheimer's will increase from 58 million in 2021 to 88 million by 2050. In Delaware, the number of people 65 and older with Alzheimer's is noted at 19,000 in 2020 and this number is projected to increase to 23,000 by 2025. Studies indicate that individuals with Alzheimer's live an average of 4-8 years after diagnosis and many may live as long as 20 years.

Approximately two-thirds of dementia caregivers are women, 30% are age 65 or older; over 60% are married; and over one-half of caregivers are assisting a parent or in-law with dementia. About 10% of caregivers provide help to a spouse with dementia. Approximately one-quarter of dementia caregivers are those of the "sandwich generation" i.e., caregivers that are caring not only for an aging parent but also for a child.

This range of life expectancy means that the advancement of the disease can be a slow and uncertain progression leading to uncertainties as to the level of care that will be needed. Help may begin as "once in a while" assistance and then possibly escalate to 24/7 care over years, which can be a difficult road map to manage" (Eidschun, A. et al. 2021).

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in consumer-directed personal assistance services (CDPAS) to 7 days per week, 24 hours per day - split shift is substantiated.