Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's Disease.
Treatment:  Increase in customer directed personal assistance service aide hours from 30 hours per week to 84 hours per week.

The insurer denied increase in customer directed personal assistance service aide hours from 30 hours per week to 84 hours per week.  The determination is overturned.

This is a male patient with a medical history notable for late-stage Alzheimer's disease. The patient is approved for 56 hours per week of consumer directed personal assistance services. The patient and his care team requested an increase to 84 hours per week, and this request was denied by the health plan.

The patient's physician provided a letter of support for this appeal. The physician states that the patient is unable to live independently and that he requires physical assistance with ambulation, transfers, toileting, bathing, and all hygiene tasks. His dementia is advanced, and he is frequently disoriented and up at night. He urinates frequently throughout the night and requires diaper and clothing changes throughout the night. The physician recommends 24-hour care to support his needs.

The patient's care team provided a letter of advocacy as part of this appeal. The letter states that the patient's family is willing and able to provide support for the patient for 12 hours per day but would not be available the other 12 hours. Therefore, the requested increase to 12 hours per day would effectively allow the patient to have the continuous 24-hour support that he requires.

A Uniform Assessment System (UAS) was completed. The assessment was conducted via teleconference in a nursing home where the patient has been residing. At the time of the assessment, the patient was oriented to person and place only. His recall was 0/3 at five minutes, and he is not able to direct his own care. For his Instrumental Activities of Daily Living (IADLs), he requires total dependence for meal preparation, housework, finances, phone use, and shopping. He requires maximal to extensive assistance for all others. For his activities of daily living (ADLs), he required supervision for bathing, hygiene, and dressing. He was independent for all others. The report states that he has full continence of bowel and bladder but still wears pullups for incontinence care and is able to change them independently. The assessment was repeated and demonstrated that he requires maximal to extensive assistance for all ADLs, which is more congruent with the reports from his physician. It also reflected that he is frequently incontinent of urine. At issue is the medical necessity of increase in customer directed personal assistance service aide hours from 30 hours per week to 84 hours per week

The requested health service of increase in customer directed personal assistance service aide hours from 30 hours per week to 84 hours per week is medically necessary for this patient.

The patient's care needs are extensive. He has advanced dementia, is incontinent of urine, and requires hands on assistance for all ADLs and IADLs. His care needs can be expected to be continuous and unscheduled in nature. He requires 24-hour care, and his family is willing to provide informal support for 12 hours per day. It is medically necessary and appropriate for the patient to be provided with personal care assistance the other 12 hours each day to meet his personal care needs.