Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, Short-term memory loss, Urinary incontinence.
Treatment: 24 hours per day, 7 days per week (live-in), Personal Care Services, Level 2.

The insurer denied coverage for 24 hours per day, 7 days per week (live-in), Personal Care Services, Level 2. The denial is overturned.

This is a female patient with a medical history of Alzheimer's dementia, seizure disorder, pulmonary embolism (on Eliquis), urinary incontinence, arthritis, osteopenia, gait disturbance, falls, left displaced femur fracture (status post intra medullary nailing), back pain and thrombocytopenia. The patient was hospitalized following a fall with a femoral fracture. She was subsequently sent to subacute rehab (SAR). She was re-hospitalized for treatment of a urinary tract infection and pulmonary emboli, and again after 2 falls.  The patient was discharged home and since her hospital discharge, the patient was noted to be mainly wheelchair bound, requiring assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs) except eating. The patient wears diapers 24/7 for urinary incontinence, and had early changes of a decubitus ulcer on the right ear and on the right side of the thigh at an office visit. The patient lives alone and receives 9 hours of home health aide services daily. The daughter lives in the same building. It was felt that the patient would benefit from split shift services to keep her safe in the community. In a Telephonic Uniform Assessment System (UAS) - New York Comprehensive Community Health Assessment report, the patient is noted to be alert and oriented x 2, and currently residing in a facility. Extensive assistance was required for ADLs, and she was using an assistive device for walking. She was independent, setup help only for bed mobility. Frequent urinary incontinence was noted. Per the Community Health Comparison Report, the patient could now not be safely left alone. The patient's daughter notes that the patient has dementia, is incontinent of urine and needs turning every 4 hours. 

The patient is approved for 9 hours/day, leaving no formal services for 15 hours/day. The UAS was done 2 weeks before the patient left the SAR facility. Dementia, incontinence and the need for assistance with transfers and ambulation have been noted since. The patient is noted to have trouble making her needs known, including when incontinent. She needs hands-on assistance with toileting. She has had several falls, one resulting in a hip fracture. She needs T&P (Temperature and Pressure [relief valve]) every 4 hours, and as she has short-term memory loss and physical limitations she cannot be expected to do this herself. She already has early changes of pressure sores. This reviewer's disagreement with the insurer is based on how much weight is given to the patient's status after the SAR stay. The number of hours to be approved is limited by what is requested. The patient has needs beyond supervision 24 hours/day. A live-in aide is not likely to get 5 hours uninterrupted sleep in an 8-hour period. 

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

Based on the above, the medical necessity for 24 hours per day, 7 days per week (live-in), Personal Care Services, Level 2 is substantiated. The insurer's denial is overturned.