Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease
Treatment: consumer and self directed personal assistance services, 24 hours a day, 5 days a week (split-shift) for a total of 120 hours
The insurer denied coverage for consumer and self directed personal assistance services, 24 hours a day, 5 days a week (split-shift) for a total of 120 hours
The denial is overturned.

This case involves a patient of advanced elderly age with Alzheimer's disease who was being assessed for increasing consumer and self directed personal assistance services, 24 hours a day, 5 days a week (split-shift) for a total of 120 hours. The documentation provided for the review included a prior assessment and a more recent assessment. The initial assessment indicated that the patient required assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), shopping, house work, and to stay free from falls. The patient lived alone in an apartment on the second floor with 1 bedroom and 1 living room. He was moderately impaired in terms of cognition with decisions consistently poor or unsafe. The patient always required cues/supervision. He had a decline in mental health in terms of memory problems. He was forgetful and had episodes of confusion. Wandering was an issue, although not exhibited in the 3 days prior to assessment. At the time of the assessment, the patient was receiving 42 hours a week of CDPAS  (consumer directed personal assistant services). He was having daily episodes of urinary incontinence and bowel incontinence and required adult pull-ups. He had moderate fatigue due to diminished energy and mild levels of pain occurring intermittently. The patient's last recorded fall was recent, which required hospitalization. The assessment stated the patient met the need for 120 days continuous services, required assistance with more than 2 activities of daily living and was documented with Alzheimer's or dementia. He was expected to need continued services for a period of 120 days or more from the assessment date. When he was reassessed, the patient sitting conditions are unchanged. He continues to require extensive to total dependence on food preparation, managing medications, phone use, navigating stairs, shopping, and transportation in addition to most activities of daily living. He continued to use a walking aid with his primary diagnosis considered Alzheimer's disease. He had no reported falls in the last 90 days and continued to have diminished energy. He reported moderate levels of pain occurring intermittently and was noted to have a strong and supportive family.  The assessment outcomes were relatively unchanged from the previous date. An appeal was submitted regarding the denial of coverage for an increase to a total of 120 hours a week of personal assistant services. The appeal stated that the patient is elderly, lives alone in the community with a diagnosis of Alzheimer's disease, depression, diabetes mellitus, orthostatic hypotension, iron deficiency anemia, and bowel/bladder incontinence. He was currently receiving 40 hours/week (8 hours/day, for 7 days/week) and consumer and self-directed personal assistant services. He is at risk for falls, injury, and requires supervision for ADLs around-the-clock. Additionally, given his incontinence, he requires frequent diaper changes to prevent skin breakdown and hospitalization.  

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 and self directed personal assistance services, 24 hours a day, 5 days a week (split-shift) for a total of 120 hours is substantiated.