Appeal type: Medical necessity
Decision: Upheld

 
Diagnosis: Cerebral Infarction, Hemiplegia

Treatment: 130 hours/week, Consumer Direct, 1 Client

The insurer denied coverage for 130 hours/week, Consumer Direct, 1 Client.

The denial is upheld.

The patient is seeking coverage for 130 hours/week of consumer directed, 1 client.  The patient was diagnosed with cerebral infarction, type 2 diabetes mellitus without complications, flaccid hemiplegia, unsteadiness on feet, chronic fatigue, neuropathy, incontinence without sensory awareness of bladder and bowels, dementia, cardiac murmur, and hyperlipidemia.

A comprehensive routine assessment was completed on the patient.  There was a goal to remain safe at home and in the community.  The patient's granddaughter spoke on their behalf due to dementia, cognitive impairment, and impaired hearing.  The patient's cognitive skills for daily decision making were moderately impaired.  Decisions were consistently poor or unsafe.  Cueing/supervision was required at all times.  There was no change in decision making as compared to 90 days prior.  There were short-term and procedural memory problems.  The granddaughter reported that the patient was not self-directing.  The patient was able to make their basic needs known.  The patient was forgetful and would forget if a family member visited them.  The patient would be unable to activate a personal emergency response system.  The granddaughter reported that the family took turns staying with the patient.  The patient's son and daughter-in-law lived on the first floor of the same house.  The patient was sometimes understood and could sometimes understand others.  There was severe difficulty with hearing and minimal difficulty with vision.  At the time of assessment, the patient did not answer any questions.  The patient smiled and seemed confused.  The patient had hearing aids, but the granddaughter reported that the patient would take them out and throw them.  The patient refused to wear glasses.  The granddaughter reported that the patient would get anxious at times when they would try to put a blanket on her, when they would put diapers on her, and when they would turn and reposition her in bed.  The patient had a history of wandering.  The granddaughter reported that the patient attempted to get up from bed 1 week ago and had fallen.  The patient was totally dependent for meal preparation, ordinary housework, managing finances, managing medications, phone use, stairs, shopping, transportation, bathing, personal hygiene, dressing of the upper body, dressing of lower body, toilet transfer, toilet use, bed mobility, and required maximal assistance for eating.  There was a decline in activities of daily living (ADL) status as compared to 90 days prior.  The patient's overall self-sufficiency had deteriorated when compared to 90 days prior.  The granddaughter reported that the patient was bedbound and that everything was done at the bedside.  The patient had sponge baths daily and was transferred to the shower 1 time a week with 2 people assistance.  The patient was not transferred to the toilet.  The patient utilized diapers.  The patient was dependent on their caregivers to clean and wash them.  The patient needed to be turned and repositioned.  The granddaughter reported that the patient needed supervision at all times due to wandering.  The family tried to provide nighttime care as needed.  The granddaughter reported that pull-ups and liners were changed every hour due to diarrhea.  The patient exhibited unsteady gait daily in the last 3 days.  The patient was unable to finish normal day-to-day activities due to moderate fatigue.  Per the tasked based assessment tool, the patient's current service hours were 112/week.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 130 hours/week, Consumer Direct, 1 Client is not substantiated.