Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Acute kidney injury (AKI), hypertension (HTN), hyperlipidemia, incontinence, memory problems, hypothyroidism, osteoarthritis, osteopenia, weight loss, glaucoma, allergic rhinitis

Treatment: Increase in Personal care services

The insurer has denied an increase in personal care services to 24 hours per day live-in, 7 days per week.  That denial was reversed.

This is a geriatric patient. The patient's daughter reports that the patient has had a gradual cognitive decline, described as poor memory. She worsened after hospitalization for dehydration and acute kidney injury. Since then she is more dependent, unable to manage finances, or remember to take her medications. She cannot go out alone. She does not use the appropriate accommodations to urinates and defecate, and she becomes easily agitated and angered. Furthermore, the patient often resists bathing and is in need of redirection and frequent reminders to manage her personal care needs. The patient's husband is unable to assist with her care. Recently, he attempted to help the patient with personal hygiene, but subsequently they both fell. The request is for an increase in home attendant hours to 12 hours per day, 7 days per week.

The records from the rehab facility indicate that the patient's mental status was confused, disoriented and with memory impairment.  The physical therapy (PT) and occupational therapy (OT) discharge notes indicated that patient showed some improvement from admission, but needed assistance for activities of daily living (ADLs) ranging from minimal to maximal. Both PT and OT recommended 24 hour care. The patient's mental status was a significant factor in the patient's inability to perform at a higher level, and with consistency. One of the consequences of dementia is the loss of ability to perform ADL independently.

Another medical condition that may be affecting the patient's ability to perform ADLs is osteoarthritis. It was noted as a problem in the Uniform Assessment Form (UAS) (affecting the knee, pain noted as daily) and is likely to still cause symptoms. When a person with dementia has pain, it is not always reported by the person or identified by others in the usual way. For example, it may be expressed by behavioral changes, decreased appetite, or sleep disturbance. 

The patient's daughter and son are involved in the patient's care, but they do not live with the patient. The patient needs assistance with ambulation, transfers, and toileting/incontinence care. These ADLs occur at various and unpredictable times of the day and night. For a person with dementia the frequency can be even more unpredictable, as confusion and disorientation may cause the person to think, for example, that it is time to get up during the night, or do some unnecessary activity and try to get up and walk unassisted. At this point, 24 hour live-in personal care services, 7 days per week is a reasonable plan to provide the patient with assistance when needed for ADLs.  

Based on the above, the medical necessity for the increase in personal care services to 24 hours per day live-in, 7 days per week is substantiated.  The insurer's denial is reversed.