Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain, graves' disease, osteoporosis, and major neurocognitive disorder due to Alzheimer's disease. 
Treatment: 24 hours per day, 7 days per week (split shift). Total 168 hours per week Consumer Directed Personal Assistant Services (CDPAS) Level 2. 
The insurer denied coverage for 24 hours per day, 7 days per week (split shift). Total 168 hours per week Consumer Directed Personal Assistant Services (CDPAS) Level 2. 
The denial is overturned. 

This elderly patient has a history of dementia, severely impaired cognition, dry eye syndrome, and osteoporosis. She is fully dependent on others. She receives 84 hours assistance a week. The family is requesting 168 hours weekly. 

This patient has severely disabled cognition. She is able to follow simple commands only.  She is unable to call 911. She is totally dependent for all activities of daily living (ADLs). Bed is wet every night and her bed is wet in morning when the home health aide (HHA) comes. She can not walk or move without assistance because she is unsteady due to left leg lymphedema. She wears pullups at night but wets herself overnight but there is no one to change her and she is not able to do it herself due to dementia. Thus, the 24 hours a day, seven days a week of consumer directed personal assistant services (CDPAS) should be approved. 

"ADL is used as an indicator of a person's functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life. Measurement of an individual's ADL is important as these are predictors of admission to nursing homes, need for alternative living arrangements, hospitalization, and use of paid home care. The outcome of a treatment program can also be assessed by reviewing a patient's ADLs. 

In 2011, the United States National Health Interview Survey determined that 20.7% of adults aged 85 or older, 7% of those aged 75 to 84, and 3.4% of those aged 65 to 74 needed help with ADLs." (Edemekong, P. F. et al. 2022). 

"Global ageing is becoming severe, and an increasing number of older adults choose to stay in their homes as they age; internationally, the demand for health care in home or community settings has increased. However, safety in home for elderly people is a challenge. Although there is no clear definition of home care safety, safety related to home care generally includes two main aspects: personal care and home health care. Scholars usually choose the incidence of adverse events in home care as an operational indicator to measure the safety of home care. 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." (Cao, S. et al. 2021). 

Based on the above, the insurer's denial must be reversed. 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 24 hours per day, 7 days per week (split shift). Total 168 hours per week Consumer Directed Personal Assistant Services (CDPAS) Level 2 is substantiated.