Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia 

Treatment: 24 hours per day, 3 days per week (split shift), total 72 hours per week, personal care services, level 2; 24 hours per day, 4 days per week (split shift), total 96 hours per week consumer directed personal assistance services (CDPAS) level 2. Combined total 168 hours per week CDPAS level

The insurer denied coverage for 24 hours per day, 3 days per week (split shift), total 72 hours per week, personal care services, level 2; 24 hours per day, 4 days per week (split shift), total 96 hours per week consumer directed personal assistance services (CDPAS) level 2. Combined total 168 hours per week CDPAS level

The denial is overturned

This is a patient with chronic medical problems including osteoarthritis, unsteady gait and progressive dementia.  The patient lives alone in a private residence.  The insurer approved 11 hours per day, 3 days per week, total 33 hours per week, personal care services, level 2; 44 hours per week consumer directed personal assistance services (CDPAS) level 2; combined total 77 hours per week.  The request is for 24 hours per day, 3 days per week (split shift), total 72 hours per week, personal care services, level 2; 24 hours per day, 4 days per week (split shift), total 96 hours per week consumer directed personal assistance services (CDPAS) level; combined total 168 hours per week CDPAS level, leading to an external review. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as severely impaired.  The patient is reportedly total dependent for performing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires maximal assistance for bathing and lower body dressing.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing, toilet transfer/use, locomotion and ambulation (uses a rollator).  The patient is independent for eating and bed mobility.  The patient is reportedly frequently incontinent of bladder and bowel.  There have been no reported falls over the prior 90 days.  The patient's functional ability has modestly declined when compared to the UAS report.  

The patient's clinical condition, cognitive impairment and functional decline are at a level and unpredictable as to require the requested "two 12 hour split shift home healthcare."  The documentation shows the patient is elderly, lives alone, has dementia with visual hallucinations, an unsteady gait with frequent falls, and frequent bladder and bowel incontinence.  The patient lives alone and their daughter is unable to help.  The patient is frequently left in dirty diapers all night long because the patient is unable to ambulate independently to the bathroom at night once their aide leaves.  
 
The healthcare plan did not act reasonably, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).  

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, 3 days per week (split shift), total 72 hours per week, personal care services, level 2; 24 hours per day, 4 days per week (split shift), total 96 hours per week consumer directed personal assistance services (CDPAS) level 2; combined total 168 hours per week CDPAS level is substantiated.