Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's Disease

Treatment: 56 hours/Week, 8 hours x 7 days; Personal Care Aide- Level 2 Personal Care Aide

The insurer denied coverage for 56 hours/Week, 8 hours x 7 days; Personal Care Aide- Level 2 Personal Care Aide

The denial is upheld 


This case pertains to an elderly patient who lives in a one-bedroom apartment with their spouse on the 7th floor with a working elevator and has a handicap accessible entrance. The patient's diagnoses are Alzheimer's disease, anxiety, bipolar disorder, chronic obstructive pulmonary disease (COPD), cancer, coronary artery disease, depression, diabetes, heart failure, hip fracture, schizophrenia, and stroke/cerebrovascular accident (CVA). The patient's medications include Amlodipine, Aspirin, Finasteride, Levothyroxine, Nitroglycerin, Ocuvite, Synthroid, Tamsulosin, Tylenol, Vitamin C, and Vitamin D.

The provider wrote a letter of appeal. The provider noted that due to the patient's rapid cognitive, physical, and functional decline, the patient can no longer independently perform activities of daily living (ADLs) independently. The patient requires daily assistance with reminders, preparation and administration of medications and meals 3 times a day, self-care, household chores, shopping, transportation, and doctor's appointments. It is medically necessary that the patient has 8 hours a day 7 days per week to maintain their current health and prevent their illness from progressing.

The insurer sent a letter denying the request for 56 hours per week of personal care aide. The plan approved 28 hours per week, 4 hours per day x 7 days per week of personal care aide. 

Another letter from a later date from the insurer made note that the member had requested additional hours while their spouse was in the hospital. Prior to the request the patient was approved 28 hours per week and the patient's spouse was also approved 28 hours per week. On appeal, the patient was approved an increase to 42 hours per week which allowed an additional 14 hours to assist with care.

The patient requires limited assistance with personal hygiene, ambulation, and toilet transfers. The patient is independent with bed mobility and eating. The patient is frequently incontinent for bladder and is continent for bowels. The patient reported one fall in the past 30 days. The patient denies any hospitalizations within the 90 days preceding this assessment. 

The task-based assessment tool noted the need for 22.16 hours per week of personal care aide services. An addendum letter noted the patient was requesting additional hours while their spouse was hospitalized. There is no indication at this time that the patient requires additional hours. The patient is receiving 6 hours per day currently. It is uncertain whether the patient's spouse is still in the hospital. The decision to deny 56 hours per week is upheld.

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 56 hours/Week, 8 hours x 7 days; Personal Care Aide- Level 2 Personal Care Aide is not substantiated.