Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Depression, Anxiety
Treatment: Increase Consumer Directed Personal Assistance 
Service Aide From 49 Hours Per Week To 84 Hours Per Week
The insurer denied: Increase Consumer Directed Personal Assistance Service Aide From 49 Hours Per Week To 84 Hours Per Week
The denial is overturned.

The patient is an elderly female. She has dementia, depression, and anxiety. The health plan's denial of coverage of increase consumer directed personal assistance service aide from 49 hours per week to 84 hours per week is under review. The health plan denied coverage of the increase because there was not change in need for assistance with ADLs (activities of daily living) between nurse assessments. There is an appeal letter from the patient's daughter indicating that the patient's condition has significantly deteriorated compared to two years ago. It is dangerous for the patient to be left alone. She lives alone. She has dementia, major depression, and panic attacks when in an unfamiliar setting. She becomes disoriented and blanks out in memory. She has fallen. She was ill in the beginning of this year. She needs to be seen by doctors constantly and receives outpatient physical therapy. She cannot be left alone. She needs diaper changing every two to three hours. She needs assistance with ADLs (activities of daily living). Daily logs have been provided showing constant assistance from 8 in the morning to 8 in the evening with eating, bathing, hygiene, dressing, tolerating, medication, and housekeeping. A letter from the patient's provider notes the patient's cognitive and physical condition has declined. She is weaker and more forgetful. She is unable to care for herself and requires constant supervision. A letter from another provider notes the patient's mental condition has deteriorated over the last two months. She is incapable of self-care.

The requested Increase Consumer Directed Personal Assistance Service Aide From 49 Hours Per Week To 84 Hours Per Week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase consumer directed personal assistance service aide from 49 hours per week to 84 hours per week is under review. The health plan denied the increase because there was not change in need for assistance with ADLs (activities of daily living) between nurse assessments performed 6 months apart. This patient has multiple chronic conditions, including dementia. Appeal statements indicate that there has been a deterioration in the patient's cognitive and physical status over the past few months. She needs assistance with ADLs (activities of daily living), including diaper changing every two to three hours. She lives alone. She has a history of falls. Daily logs show the patient receiving continuous care with all ADLs (activities of daily living) over a twelve-hour period. The information provided shows that this patient has significant limitations in functioning. The approved consumer directed personal assistance service aide from 49 hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase to 84 hours per 
week is medically necessary.