Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia

Treatment: Increase in Personal Care Aide Services for a total amount of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The insurer denied the increase in personal care aide services for a total amount of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week. The denial was reversed.

This is an elderly male patient with a history of congestive heart failure, osteoarthritis, glaucoma, macular degeneration and dementia. It was reported that the patient has had a rapid decline since he was diagnosis with dementia. His ability to communicate has lessened and he struggles while attempting to express himself. The patient requires assistance with eating; needing to be fed at times. Home attendant reported finding the patient with feces on his hands, feet, and the walls. He also requires assistance wiping himself after bowel movement. It was reported that the patient has had frequent falls causing injures to himself. A request for an increase in personal care assistance was made.

The patient was also noted to have very limited toileting skills. The patient needed assistance with toileting as a physical need, i.e. weight-bearing assistance for toilet transfer and cleaning himself; but also appeared to have lost recognition of what needed to be done when using the toilet (the patient's daughter reported that the patient did not know he needed to pull down his briefs, and at times, the patient used trash can or closet as a toilet). This loss of basic skills is a serious health concern, as the patient is at risk for malnutrition and dehydration from loss of eating skills; and as a result of incontinence and inadequate self-hygiene, the patient was at risk for incontinence associated skin damage (e.g. dermatitis, fungal infection). As dementia progresses, the loss of ability to perform IADLs and ADLs is an expected consequence of the disease. In earlier stages of dementia, loss of IADLs, which require higher level of cognitive function, often occurs first. In later stages, ADL skills decline. It appears that the patient is at a stage of dementia when his ADL skills are becoming increasingly impaired and therefore, the patient needs increased assistance with personal care needs, as well as IADLs.

Considering the patient's physical and cognitive deficits, it is apparent that the patient can no longer safely and effectively manage his daily activities without help from a caregiver. The patient needs assistance with ADLs that occur at unscheduled times throughout the day and night, including transfers, walking, toileting and incontinence care. The nighttime activity records from the daughter indicate the patient's frequent need to get out of bed and go to the bathroom. Even with a commode, the patient would need assistance with transfer to the commode and assistance and cueing for using the commode properly and safely. The patient needs a caregiver present for all meals. For older people who do not eat sufficiently at meal time, it is often necessary to attempt to offer food at other times during the day; a small amount at a time. 

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

The carrier's denial of coverage for the requested Personal Care Aide: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is reversed.  The medical necessity is substantiated.