Appeal type: Medical necessity
Decision: Overturned

Diagnosis: diabetes, chronic kidney disease, hypertension, depression, macular degeneration, dementia, and congestive heart failure

Treatment: Consumer Directed Personal Assistance services 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week

The insurer denied coverage for Consumer Directed Personal Assistance services 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week

The denial is overturned

 
According to the medical records, the patient is an advanced elderly patient with a history of diabetes, chronic kidney disease, hypertension, depression, macular degeneration, dementia, and congestive heart failure. The patient had multiple falls in the past and has unsteady gait. The patient is dependent on all her activities of daily living (ADLs) and has increased debility due to her dementia. Request is for Consumer Directed Personal Assistance services 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week.
The patient has multiple medical conditions and is becoming more debilitated due to her dementia. She is dependent for all her ADLs. She needs home assistance to be safe, at least 12 hours daily.
"In recent years, the healthcare system has continued to its shift away from its historically predominant focus on inpatient care. However, patient safety in the home care setting is less well understood than patient safety in other settings. Elderly people are at a higher risk of safety related events than younger people due to the natural process of ageing and their health status due to multiple chronic diseases. Unique family situations, regarding the physical environment, caregiver knowledge, application of medical devices and availability of care resources, make home care safety in older adults complicated. The Joint Committee has been developing "home care safety goals" since 2002 and updates them annually to help caregivers address safety challenges. The World Health Organization devised an international classification system of patient safety concepts for all care settings, including the home in 2009 (World Health Organization, 2009). Research on the safety of home care for elderly people has gradually increased over the past decade." (Cao, S. et al. 2021).
"As for any client, caregivers can assist with Activities of Daily Living (ADLS) and Instrumental Activities of Daily Living (IADLS). The ADLS include help with personal care such as toileting, bathing, dressing and mobility supervision. The IADLS may include everyday tasks such as laundry, meal preparation, light housekeeping, and errands. For clients with dementia, there is also a component of continually managing the behaviors of the disease, such as wandering, agitation, and anxiety, among others. Caregivers who have dementia training understand how to keep a client engaged in conversation and cue them through the steps of the activity to be performed. They know how to manage unpredictable behaviors through redirection in order to accomplish tasks at hand, and keep both the client and themselves safe." (Eidschun, A. et al. 2021). 
Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Consumer Directed Personal Assistance services 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week is substantiated.