Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease
Treatment: Consumer directed personal assistance services (CDPAS) 7 days per week, 24 hours per day, live-in, 91 hours per week
The insurer denied coverage for CDPAS 7 days per week, 24 hours per day, live-in, 91 hours per week.
The denial is overturned.

A recent comprehensive community health assessment noted cognitive skills for daily decision-making are moderately impaired, decisions are unsafe, and cues/supervision are required at times. It is further noted that there has been a decline in decision-making as compared to 90 days ago. The patient is reported to have memory problems. The evaluator indicates the patient needs nursing facility level of care, has a need for 120 days of continuous service, has more than two activities of daily living (ADLs) at limited assistance level or above, and has Alzheimer's or dementia and more than one activity of daily living at supervision level or above. The evaluator further determined the patient cannot be left alone safely. The Mini-mental state examination documents a total score of nine consistent with severe cognitive impairment.

A letter of medical necessity from the patient's psychiatrist, notes that 24 hour care at home is needed because the patient gets periodically agitated on delusional beliefs, which require constant monitoring to ensure the patient is not hurting themselves or others. The provider goes on to note the patient has a proven track record of trying to escape their house and wander aimlessly, and they have already been picked up at the police station by their child after trying to flee their home. They further note that the patient's former apartment was flooded when they left the kitchen faucet on, leaking down to the first floor from the fourth floor. The patient's thoughts are often confused and tend to be paranoid, psychotic, and compulsive, which can lead to persecutory ideation that somebody is either hurting them or their family and leads the patient to take rash actions that do not make rational sense and can be dangerous to the patient and their family. The provider notes that the patient currently lives with their child, and without constant supervision of medication administration and supervision of behavior, the patient would need to be placed in a long-term institution with 24 hour dementia care. The provider feels that maintaining the patient and their current home situation is more preferable and cost-effective than placement in a long-term institution. 

The health care plan suggested the patient is able to ambulate, transfer, and use the toilet with limited assistance and without the use of any assistive device, and the patient is able to feed themselves with meals that are prepared in advance by their personal care assistant. The plan further suggested that ADLs needs, such as grooming, dressing, bathing, walking, locomotion, transferring, toileting, meal preparation, and feeding can be safely and adequately met through the combination of the approval of a personal care assistant service 7 days per week, 5 hours per day. This reasoning by the health care plan is unfounded and in contradiction with the comprehensive community health assessment and documentation provided by the patient's treating providers. The documentation provided clearly document a need for full-time care, not care 35 hours per week. As noted in the reference guideline for Alzheimer's disease management, home health care services are supported for the treatment of patients with Alzheimer's disease.

The patient would otherwise require nursing facility level of care if they do not receive consumer directed personal assistance services (CDPAS) 7 days per week, 24 hours per day, live-in, 91 hours per week.

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

The insurer's denial of coverage for CDPAS 7 days per week, 24 hours per day, live-in, 91 hours per week is overturned. Medical necessity is substantiated.