Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's Disease.
Treatment: Increase in personal care assistance from 70 to 84 hours per week.
The insurer denied the increase in personal care assistance from 70 to 84 hours per week. 
The determination is overturned.

This is a patient with a medical history notable for Alzheimer's dementia. The patient was receiving 8 hours per day, 7 days per week (56 hours per week) of personal care assistance. The patient and her family requested an increase to 12 hour per day, 7 days per week (84 hours per week), and this request was partially denied; the health plan did approve an increase to 9 hours per day, 7 days per week (63 hours per week).

The patient is under hospice care, and notes from the treating provider were reviewed. A home visit note states that the patient has been progressively declining and requires assistance with all Instrumental activities of daily living (IADLs) and activities of daily living (ADLs). She is a two person assist for standing. She can no longer feed herself. She lives with her daughter, who has not been able to provide for all of her personal care needs, as she has been worsening. She has had sundowning, but that is reportedly improving with changes to her medication regimen. Notes from prior visits by the hospice physician corroborate a steady decline in functional capacity.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was unable to participate due to cognitive impairment. She was oriented to person only and not able to direct her own care. For her functional status, she required total dependence for meal preparation, housework, finances, shopping, and transportation. She required maximal assistance for medications and stairs. For her ADLs, she required maximal assistance for bathing, dressing upper/lower body, and toilet use. She required extensive assistance for hygiene, walking, locomotion, and toilet transfer. She required limited assistance with bed mobility and eating. She was frequently incontinent of urine and infrequently incontinent of stool, using diapers and pull ups for incontinence care. A task tool recommended 38.94 hours per week to address her personal care needs. At issue is the medical necessity of an increase in personal care assistance from 70 to 84 hours per week.

The requested health service/treatment of increase in personal care assistance from 70 to 84 hours per week is medically necessary for this patient.

The patient's UAS was completed and the patient appears to have declined since that time. The physician's notes describe a level of assistance for ADLs which is greater than what is reflected in the UAS. This may be due to her progressive decline, which is expected in the course of advanced dementia.

She has incontinence of urine and stool and is unable to toilet independently. She is not able to make her needs known. Her family has been assisting but have reached their capacity to do so. If the family cannot provide additional support, the personal care hours are medically necessary to meet her functional care needs. Without prompt attention to toileting needs, which are unscheduled and unpredictable, the patient would be prone to skin breakdown and/or infection.