Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diverticulitis, Alzheimer's disease, hypertension, hypercholesterolemia and scleral hemorrhage. 

Treatment: Increase in customer directed personal assistance service (CDPAS) hours from 42 hours per week to 70 hours per week. 

The insurer denied coverage for increase in customer directed personal assistance service (CDPAS) hours from 42 hours per week to 70 hours per week. 

The denial is overturned. 

This case involves a female diagnosed with Alzheimer's disease. The patient had a history of diverticulitis, hypertension, hypercholesterolemia, and scleral hemorrhage. In assessment, it was noted that the patient had moderate impairment in her ability to make decisions. Her decisions were consistently poor or unsafe. She required cues/supervision at all times. She had memory problems. She did not respond to questions directly. The patient's care provider reported that the patient was confused most of the time and required multiple prompted/directive to complete tasks. Her ability was limited in making concrete requests. She had limited vision. She was not able to see newspaper headlines but could identify objects. 

She required total dependence for meal preparation, housework, and managing finances. She needed maximal assistance in managing medications. She required maximal assistance with weightbearing support. It was noted that the patient was increasingly requiring care with regard to activities of daily living including toileting, medication administration, feeding, and monitoring of seizures. The patient had a seizure. Her medication list included Keppra, galantamine, and trazodone. The provider recommended an increase in aide services to 70 hours a week. 

The increase in customer directed personal assistance service (CDPAS) hours from 42 hours per week to 70 hours per week was medically necessary. Per the cited references, personal Assistance Services are aimed at assisting the individual to complete tasks of daily living that would be performed independently if the individual had no disability. Medical necessity services are those that will or are reasonably expected to prevent the onset of an illness, condition, or disability, are reasonably expected to reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability, will assist the participant to achieve or maintain maximum functional capacity in performing daily activities, and will provide the opportunity for the patient to have access to the benefits of community living. In this case, the patient was increasingly requiring care regarding activities of daily living including toileting, medication administration, feeding, and monitoring of seizures. She required assistance for all ambulation and had limited capacity to understand and make her needs known. For patients with Alzheimer's, continued decline is expected. The patient is at risk for wandering and injury. Fall prevention should be a priority. The patient needs constant monitoring to monitor for seizure activity and falls which could result in injury. Given the patient's increasing dependence on others, the increase of hours is medically necessary. The patient's care could not be provided safely at lower hours given her progression of disease. As such, the denial of coverage for an increase in customer directed personal assistance service (CDPAS) hours from 42 hours per week to 70 hours per week was not appropriate and is overturned. 

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

The insurer's denial of coverage for an increase in customer directed personal assistance service (CDPAS) hours from 42 hours per week to 70 hours per week is overturned. Medical Necessity is substantiated.