Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase in consumer directed personal assistance services (CDPAS) to 7 days per week, 24 hours per day, continuous care by more than 1 person, 168 hours
The insurer denied an increase in consumer directed personal assistance services (CDPAS) to 7 days per week, 24 hours per day, continuous care by more than 1 person, 168 hours.
The determination is overturned.

The patient resides alone. She has multiple medical conditions including abnormal gait and mobility, insomnia, osteoarthritis, hypertension, hyperlipidemia and dementia. This is a request to increase consumer directed personal assistance services to 7 days a week, 24 hours/day, continuous, more than 1 person, 168 hours/week. Presently the patient receives services 12 hours a day 7 days a week.
With the patient's multiple medical conditions, namely her dementia and gait abnormality, there is a request for increased services to 24 hours/day. She requires assistance multiple times a day across multiple aspects of daily care and need. This includes assistance with cooking, cleaning, bathing and toileting. Additionally, with her ambulatory dysfunction she also requires assistance and monitoring while ambulating.
There is a night log provided by family that demonstrates that not only during the day does she have these care needs, but at nighttime is frequently disrupted and care needs are extended through the night. There is no opportunity even for a 5-hour time for "continuous rest".
Additional physical needs reported include incontinence of which the patient is unable to respond to on her own or provide appropriate hygienic needs. She needs a walker to transfer and ambulate safely, but with her dementia she often neglects to use these tools.
According to the documentation provided, the rationale for denial from the insurance company was based on the assertion that the patient's activities of daily living needs such as grooming, dressing, bathing, ambulation, locomotion, transferring, toileting, meal preparation and feeding are sufficiently infrequent and can be safely and adequately met through the originally approved 91 hours/week: member's needs can be scheduled and thus additional care will not be necessary given the hours already approved. The plan notes that it is not required to include safety monitoring as a separate task.
The patient advocate notes that although safety monitoring is a separate task not included under the services, the patient's frequent awakenings, episodes of incontinence and trips to the bathroom require more than "safety monitoring" but assistance with activities of daily living such as ambulation and locomotion. The provided documents include a Uniform Assessment System (UAS) assessment system and personal health summary report. The comments note severe impairments in cognition. The ability to understand others is rarely or never. The ability to make herself understood is rarely or never. Informal help for her status is noted to be overwhelmed.
As above, the patient lives alone. She is noted to be dependent with her activities of daily living (ADLs). She is totally dependent for locomotion, requires extensive assistance with toileting, is frequently incontinent of urine, and has occasional incontinence of stool. She has had 1 fall in the last 30 days. They comment on the presence of dizziness, unsteady gait, hallucinations, difficulty with sleep, fatigue. She has a diagnosis of Alzheimer's and also has a diagnosis of coronary artery disease, dysthymia, hypertension, insomnia, gait abnormality, generalized osteoarthritis and urinary incontinence.
Given the patient's impacted cognition, she is unable to make her own decisions. She has significant limitations with memory and recall. She is able to hear with only minimal difficulty. Vision is only minimally impaired.
A Mini-Mental status exam was provided and the patient's score is 0. Of note, this was done over the telephone due to the coronovirus 2019 (COVID-19) pandemic.
Additional history includes a recent diagnosis and hospitalization for COVID-19 followed by a stay at a rehabilitation facility. Upon returning back to her residence she has been weaker and unable to ambulate. The physician's note also comments that she has fallen out of bed twice.
At issue is the medical necessity of an increase in consumer directed personal assistance services (CDPAS) to 7 days per week, 24 hours per day, continuous care by more than 1 person, 168 hours.

The requested level of services are medically necessary and appropriate. This is medically necessary due to the patient's advanced age and severe dementia as well as ambulatory dysfunction. The patient's dementia creates around-the-clock care needs. She is unable to make her needs known. She is unable to understand commands and directions letter provided to her. This provides significant challenges in administering care to this patient. The patient is likewise unable to make any of her care needs known.
Additionally she has urinary and, at times, fecal incontinence. This is noted to be around-the-clock. At times when she does use the toilet, she requires assistance with ambulating, transferring, toileting and cleaning. These needs can occur at all hours of the day irrespective of a schedule. Without care present, the patient is at risk of falls, injury, morbidity and mortality. The patient's needs are so frequent that they would not allow a personal care worker to have at least 5 hours of continuous/uninterrupted sleep as supported and documented by the night log.