Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia

Treatment: Consumer directed personal assistance program (CDPAP); 12 hours per day- 7 days a week, for a total of 84 hours per week

The insurer denied coverage for consumer directed personal assistance program (CDPAP); 12 hours per day- 7 days a week, for a total of 84 hours per week

The denial is overturned

This patient has significant functional impairment associated with various medical conditions, and needs assistance with all daily activities. The patient lives alone. As per Uniform Assessment System (UAS), there is one informal helper (description and frequency of activities of daily living (ADL)/instrumental activities of daily living (IADL) help is not noted). The patient primarily relies on personal care services to assist with ADLs and IADLs, provided through Consumer Directed Personal Assistance Program (CDPAP). The patient receives CDPAP services 42 hours per week. The final adverse determination letter included a report from the patient's son that the patient's health status declined; the patient needs more help due to a fall, and weakness related to COVID. The patient (via designee) requested increase of CDPAP services to 84 hours per week, which was denied. External appeal was requested.

The most recent UAS provided for review was done. Functional status for IADLs indicates the patient is totally dependent for housework, stairs, transportation; the patient needs maximal assistance for shopping, meal preparation, managing finances and medications; extensive assistance for phone use. For ADLs, the patient is totally dependent for bathing, dressing lower body, locomotion; the patient needs maximal assistance for personal hygiene, dressing upper body, walking, transfer toilet, toilet use, bed mobility, and eating.

Functional decline in older people is often due to the effects of multiple medical conditions which adversely affect physical and/or cognitive function. Other contributing factors include economic and social circumstances, e.g., caregiver support. Functional decline is often accelerated by an acute change in medical status. The patient most likely experienced functional decline from chronic medical conditions over an extended period of time; this was likely recently exacerbated by acute events (hospitalized due to fall and due to COVID). For an older person, it can become increasingly difficult to return to the prior level of function following an acute medical event. Rehabilitation can help, but may be limited due to underlying medical conditions, e.g., chronic pain may limit participation in rehab activity; cognitive impairment can limit ability to learn/remember ADL skills. 

For a person with dementia, loss of ability to perform daily activities is an expected consequence as cognitive impairment progresses. Cognitive decline for IADLs usually precedes decline for ADLs, as IADLs generally require higher level of cognitive function. The patient needs substantial help with most IADLs and it is likely that cognitive impairment is a significant contributing factor in addition to their physical limitations. Regarding ADLs, in later stages of dementia the affected person may not remember, recognize or know what to do for basic daily activities. It is unclear to what extent cognitive decline affects the patient's ability to perform ADLs. The patient's memory impairment and poor decision-making for daily tasks can affect safety during ADL performance. Cues, reminders, prompting are part of the scope of care for personal care aides when providing assistance with daily activities.

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 consumer directed personal assistance program (CDPAP); 12 hours per day- 7 days a week, for a total of 84 hours per week is substantiated.