Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Late Onset Alzheimers.

Treatment for consumer directed personal care assistance at 84 hours per week.

The insurer denied coverage for consumer directed personal care assistance at 84 hours per week.

The denial is overturned.

This female reportedly had a diagnosis of late onset Alzheimers with Behavioral Disturbance. She reportedly had worsened cognitive decline and functioning and was receiving 51 hours per week of direct personal care assistance, but the request was for more of these services at 84 hour per week.
   
The Department of Health reports that personal care services (PCS) helps people with everyday tasks including activities of daily living or household tasks. It also states that personal care attends to the physical needs of people disabled or otherwise unable to take care of themselves. Such Activities of Daily Living (ADL) include bathing, showering, management of bodily fluids, toileting, feeding, ambulating, transferring from bed to chair or wheelchair, or in and out of the tub or shower, grooming, taking care of teeth or mouth, housekeeping, or meal preparation. It involves a physician to order the services and then a nursing and/or social work assessment to be done. 

The American Psychiatric Association (APA) Practice Guideline For The Treatment of Patients With Alzheimer's Disease and Other Dementias reports that choice of specific treatments for a patient with dementia begins with the establishment of a specific diagnosis and an assessment of the symptoms being experienced by that patient. A multimodal approach is often used, combining, for instance, behavioral and psychopharmacological interventions as available and appropriate. When multiple agents or approaches are being used and problems persist or new problems develop, it is advisable, if possible, to make one change at a time so that the effect of each change can be assessed. The site of treatment for an individual with dementia is determined by the need to provide safe and effective treatment in the least restrictive setting. At the end of life, many patients with dementia are cared for in a hospice program. It also is reported that patients with dementias may benefit more from consistency, reminders, and familiarity in the environment. Also, according to Cathmandu University Medical Journal 2003 Volume 1 #3 pages 205-211 "Current Status: Alzheimer's Disease" by Gosh, R-it states that a number of general environmental and behavioral management principles can optimize safety, enhance function, and thus delay hospitalization. It also states that familiar surroundings, simple and constant daily routines, door locks to prevent wandering, protection against hot stove surfaces and toxic substances and avoidance of driving are all important safety measures. It also states that changes in the environment may worsen confusion and agitation. In dementia patients it is important that they have a familiar environment as they have cognitive decline, paranoid ideation, forgetfulness and being in a non-familiar environment is worse for the patient as a result. In this case this patient required more direct personal care services as she needed more than just supervision for safety in the home; she needed more help with ADL's. She had reports of significant cognitive deficits including confusion, memory deficits, disorientation to time and address, and she could not express an emergency plan, and could not be alone as she was wandering daily which put her at risk of harm to self. The family reportedly locked the oven and refrigerator. She reportedly had difficulty understanding, finding words or finishing thoughts, and prompting was required. She reportedly had depression, aggression almost daily, and was socially inappropriate and had disruptive behavior. She reportedly had paranoid delusions that someone was taking her money and belongings. She reportedly was prescribed medications by psychiatry and also was seen by neurology. She reportedly required some assistance walking and in bed mobility to unsteady gait and dizziness. She reportedly required maximal assistance in bathing. She reportedly required extensive assistance in personal hygiene, phone use, dressing, washing, toilet use, transportation, and meal preparation. She reportedly required total assistance in ordinary housework, finances, medication use and dispensing, and shopping. She reportedly was at risk of danger to self and unable to care for her basic needs and required more supervision in the form of 84 hours per week of direct personal care assistance services. She was a severely dysfunctional patient in need of more services. 

Personal care services at a total of 84 hours per week instead of just 51 hours per week was medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for consumer directed personal care assistance at 84 hours per week is overturned. Medical necessity is substantiated.