Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prostate Cancer; Chronic Kidney Disease; Atrial Flutter, Dementia.

Treatment: Nutritional support with Home Delivered Meals.

The insurer denied coverage for increase to 12 Home Delivered Meals per week.

The denial is overturned.  

This male patient has prostate cancer, coronary artery disease, atrial flutter, chronic kidney disease (CKD), hypertension (HTN), and dementia. He is in need of nutritional support. He is receiving personal care services through Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week. His physician is recommending home delivered meals. The insurer states meals are to be covered under personal care services. 

The patient has 5 year history of memory loss (worsening); confusion; periods of agitation. He has difficulty with word finding, difficulty speaking. Evaluation at neurobehavioral clinic was most consistent with vascular dementia. Neurology diagnosed likely advanced dementia (AD).

The patient's partner works 40 hours per week. Other relatives or friends cannot help the patient as they are busy. The patient does not want strangers in his home. The patient wants to go for a walk; but does not wear a mask; does not understand virus outbreak. The patient has a history of falls and gait difficulty but refuses assistive devices. He has recent hospitalizations and is eating less; 10 lb weight loss in a few months. 

The social worker notes that due to his medical conditions, he needs additional nutritional support, which includes adherence to a cardiac prudent, low salt, no concentrated sweets diet. The organization chosen to provide meals to the patient would be beneficial to assist in management of his dietary needs. The meals should be considered an essential part of his clinical treatment plan. 

The patient has extensive medical history lives at home with his partner. The patient has experienced functional decline over the past year. His partner is the CDPAS aide. The patient's physician requested 12 home delivered meals per week. 

Cognitive and physical functional decline are closely associated in the elderly and together contribute to overall functional impairment. Decline in ability to perform daily activities is an expected consequence of dementia. 

All of his physical limitations and cognitive impairment substantially restrict the patient's ability to prepare meals. He is dependent on others for all aspects of meal preparation (shopping, cooking, serving, clean up); except it is noted he can take some items from the refrigerator that are left for him.

Nutrition in the elderly is a central part of patient care in order to maintain adequate nutrition for basic physiologic function, and management of various medical conditions that depend on compliance with nutritional guidelines.  

Based on available information, some of the patient's risk factors for malnutrition include: chronic medical conditions associated with nutritional risk; recurrent acute illnesses requiring hospitalization; use of multiple medications; dementia/cognitive impairment; depression; impaired daily activity skills. Malnutrition in the elderly is associated with functional decline and poor health outcomes. 

Considering the patient's medical history, and physical and cognitive impairments, it is medically necessary to provide home delivered meals that are consistent with the patient's health needs. The patient's partner reported the meals the patient has been receiving over the past year are not compatible with the patient's dietary needs. The organization chosen appears to be capable of providing a variety of food choices within the patient's dietary requirements, with guidance from a dietician. 

The health plan did not act reasonably with sound medical judgment.

The medical necessity is substantiated. The carrier's denial of coverage for Meals Home Delivered Meals Increase to 12 Meal(s) per Week is reversed.