Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, Osteoarthritis
Treatment: Consumer Directed Personal Assistance Service, 9 hours a day, 5 days a week and 8 hours a day, 2 days a week, total of 61 hours
The insurer denied Consumer Directed Personal Assistance Service, 9 hours a day, 5 days a week and 8 hours a day, 2 days a week, total of 61 hours.
The denial was overturned.

This is a female patient with a history of Alzheimer's disease, anxiety, depression, hypertension, osteoarthritis, gait abnormality, urge incontinence, fecal urgency, insomnia, constipation. The patient lives with her son who is the only informal caregiver.  The patient needs assistance for all daily activities.  She currently receives Consumer Directed Personal Assistance Services (CDPAS) 8 hours per day, 5 days per week, 5 hours per day, 2 days per week; total of 50 hours per week.  The patient was previously scheduled for social day care.  It is not known how long she attended, or if she still attends; but the son's comments indicate that as his mother's condition worsened, it was very difficult to get her ready to go to day care. 
For a person with dementia, decline of ability to perform daily activities is an expected consequence of the disease as it progresses. Decline of instrumental activities of daily living (IADL) skills usually occurs before activities of daily living (ADL) decline, as IADLs generally require a higher level of cognitive function. As dementia progresses to later stages, there is increasing loss of ability to perform ADLs. As per the Uniform Assessment System (UAS), the patient was already totally dependent in most IADLs, and needed extensive or limited assistance with most ADLs. The patient's decision making capacity for daily tasks was severely impaired; and she had extensive memory impairment. These cognitive deficits result in poor judgment, decreased safety awareness, and impaired ability to perform daily tasks; and so cognitive impairment is a substantial contributing factor to the patient's functional decline. 

The patient's physical function also appears to be impaired, affecting her ability to walk and transfer; and possibly other ADLs. The patient has osteoarthritis. No details are provided, but the UAS indicates patient has unsteady gait and has difficulty moving to a standing position unassisted (transfer activity). These functional problems are often the result of pain and/or limited range of motion of lower extremities and back, which is frequently associated with arthritis. The patient advocate's report states that the patient needs a walker to ambulate and transfer safely but she does not use it (most likely due to memory impairment, and/or lack of understanding how to use a walker). 

The patient has multiple risk factors for falls, including: arthritis, unsteady gait, incontinence, history of falls, advanced age, cognitive impairment, use of medications associated with fall risk (benzodiazepine, antipsychotic and antihypertensive drugs).  
The health plan  did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for CDPAS, 9 hours a day, 5 days a week and 8 hours a day, 2 days a week, total of 61 hours is overturned. The medical necessity is substantiated.