Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia 

Treatment: Increase in personal care hours from 62 hours to 84 hours

The insurer denied coverage for increase in personal care hours from 62 hours to 84 hours. The denial reversed.

This patient is a female has had progressive functional decline, requiring increased level of assistance and supervision. She had been living with her husband, but due to his inability to care for his wife (due to his own health problems) the patient is currently living with her daughter. The apartment has no elevator and the patient needs to climb and descend 28 stairs, which requires extensive assistance. The patient has been receiving personal care services (CDPAS) and is currently approved for 62 hours per week. The daughter is requesting an increase to 84 hours per week. The patient also attends social day care 16 hours per week. The daughter stated in her letter that with increased aide hours, the patient could spend more time in her own home with her husband. The request for 84 hours per week was denied. The daughter is appealing the decision.
  
The patient has dementia. As per the UAS and the daughter's letter, it appears the patient has significant cognitive impairment, including poor decision making capacity, memory impairment, unsafe behaviors, resisting care. As dementia progresses, decline in ability to perform ADLs and IADLs is an expected consequence of the disease. When dementia co-exists with other medical conditions that adversely affect physical function, the combined effect can result in substantial disability. The patient has arthritis. Medical records are limited, but as per the UAS, the patient's symptoms include back and knee pain, difficulty bending, decreased range of motion. These symptoms and functional limitations have resulted in gait abnormality, difficulty getting up from a chair (i.e. transfers), and difficulty performing various daily tasks that require standing (housekeeping chores), bending (dressing, bathing, toileting). The UAS indicates the patient needs only supervision for walking.

Another serious problem is the patient's resistance to eating. It is not known if this behavior is all due to dementia, or if other health problems are causing decreased appetite; however, the effect is already evident, as the patient is significantly underweight. It is necessary for a caregiver to be present for extended periods of the day to help encourage the patient to eat. The patient needs the attention and assistance from a caregiver for multiple care needs as described above, including assistance with ADLs that occur at various times throughout the day. The patient's daughter is the primary caregiver. It appears she is becoming overwhelmed by the responsibility and time commitment of caring for her mother. Caregiver stress is a serious problem that can have adverse effects on both the caregiver and care recipient.

Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. In this case, it appears that the level of care the patient needs is beyond what the daughter can realistically provide. Based on the patient's care needs, it is medically necessary for the patient to have assistance throughout the day and night. When informal caregivers cannot provide all the necessary assistance, then it is medically necessary for personal care services (in this case CDPAS) to provide the care needed to address the patient's ADL and IADL needs. 
 
Personal care assistance services at 84 hours per week are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the person.

Based on the above, the medical necessity for an increase in personal care hours from 62 hours to 84 hours weekly is substantiated.  The insurer's denial is reversed.