Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-Other/Lewy Body Dementia
Treatment: Skilled Nursing Facility-Long-Term Custodial Care
The health plan denied Ongoing Long-Term Custodial Care as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient has a history of impaired vision, uncontrolled diabetes, psychosis, delusional disorder, and is noncompliant with medications. The event was precipitated by an episode of visual hallucinations along with uncontrolled diabetes and uncontrolled hypertension prompting a hospital admission. The patient was discharged from the hospital and admitted to a skilled care facility. Skilled care continued until the facility requested authorization for long-term care. Since her admission to the facility, the patient has required continuous cueing and encouragement for medication compliance. The patient remains isolated and minimally engages with peers and staff. 

The patient has no significant social supports. She lacks any family support or next of kin. She has poor insight and poor judgment. She has severely impaired vision which is further complicated by her dementia, depression, psychosis, diabetes, and hypertension. According to the physician the patient was not felt to be a good candidate for an alternative living situation such as a shelter or assisted living facility. The patient had been in a shelter prior, but her deteriorating mental status and inability to make medical decisions made this option a poor choice and that the patient has clear risks- "if patient is discharged without any close supervision, her physical condition may deteriorate significantly and soon she may end up in the hospital." It is their attestation that she requires 24/7 nursing, medical, and wellness care. The patient has extensive assistance requirements of at least 1 person with activities of daily living (ADLs) including transferring, toileting, and personal hygiene. A work-up for reversible causes of dementia was negative and the patient was diagnosed with dementia with Lewy bodies. The patient has shown significant and unintended weight loss and required nutrition consultation. The patient requires assistance with feeding to increase portion intake and maintain weight. 

It is appropriate, reasonable, and medically necessary to approve this patient for long-term custodial care services. Significant documentation has been provided including records from physicians, nursing, social work, and a nutritionist, in addition to consultation reports from psychiatry and ophthalmology. The patient has significant medical and social risk factors, making her inappropriate for discharge. Most notably is her psychosis and underlying Lewy body dementia which is further exacerbated by her blindness. She has hypertension and uncontrolled diabetes. The patient has no outside social supports and no family. She is unable to make her own medical decisions. Prior to admission the patient was residing in a shelter. With her underlying medical conditions, she was not felt to be safe or appropriate to return to this shelter. She has demonstrated a lack of capacity to make her own medical decisions and direct her own care. The shelter has refused to have her back.

It is quite apparent that without ongoing care provided at this facility the patient will almost certainly decompensate and require hospitalization again, thus increasing her risk for morbidity and mortality without these ongoing services. Information provided has supported that she has significant limitations with her ADLs. She requires assistance with transfers, ambulation and feeding.