Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lewy Body Dementia
 
Treatment: Increase in Level 2 Personal Care Services 

The insurer denied the increase in Level 2 Personal Care Services from 48 hours per week to 58 hours per week.  The denial was reversed.  

This is an elderly female patient with a medical history that includes Lewy Body dementia, full incontinence, type 2 diabetes, hypertension, instability of her gait and mobility.  It was reported that a couple years ago she was deemed an incapacitated person by the courts.  She has had personal care services that have provided 48 hours a week; 8 hours a day 5 days a week and 4 hours a day 2 days a week.  Due to her severe cognitive deficits she is in need of an increase in help.  The patient has severe cognitive decline, fully dependent on her husband.  She cannot carry out any activities of daily living (ADLs) or instrumental activities of daily living (IADLs).  She needs 24 hour care for all her needs.  The patient has a tendency to wander.  She has had multiple falls.  The husband is very helpful but cannot continue to provide care without professional help at least 10 hours per day, 7 days per week.

The patient's neurologist submitted a letter which includes the following: The patient has demonstrated progressive cognitive decline over several months and profound motor apraxia requiring assistance for all activities.  She is fully dependent on her husband for all ADLs and IADLs.  The husband is very dedicated but at this stage of dementia, the patient needs 10 hours of professional home care daily x 7 days per week.  Geriatric social worker submitted a letter that includes the following: The patient has Lewy Body dementia, full incontinence, type 2 diabetes, gait instability, hypertension.  The patient has demonstrated physical and cognitive decline since initial approval of hours.  She is unable to communicate and depends on others for all ADLs.

The patient's husband provided a detailed letter describing some of the problems encountered on a daily basis in order to provide care for his wife.  One issue is mealtime.  The husband must perform all meal preparation while watching his wife (to prevent her from wandering and getting up unassisted).  He describes the problems when his wife is in bed.  She has had frequent episodes of falling off the bed.  He describes several times in the past few months when she was partially or entirely on the pillows (next to the bed) during the night.  His wife cannot perform any ADLs without assistance from husband or home health aide.  In the past several months she has been to the Emergency Department (ED) 3 times and once to urgent care center.  She has hallucinations as part of her disease (Lewy Body).  Her speech is totally disorganized.  Items such as stove knobs and silverware are hidden to prevent her from doing harm to herself or others.  The husband feels the assessment from late 2019 does not accurately reflect his wife's condition.  He reports that the she slept during the assessment; assessor obtained information from the husband and social worker and did not observe his wife performing ADLs.

The physical and emotional stress on the caregiver can have an adverse effect on the health and safety of the person receiving care.  If the caregiver's ability to provide care is limited by personal health problems, then the caregiver may not be able to properly and safely provide the necessary assistance (e.g. weight bearing assistance may be difficult for a caregiver with pain in back or extremities).  Lack of sleep for the caregiver may cause lapses of memory or inattention to details when providing care.

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

The carrier's denial of requested increase in Level 2 Personal Care Services from 48 hours per week to 58 hours is reversed.  The medical necessity is substantiated.