Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease. 
Treatment: home care / personal care HHC (Home health care)  - level 2 personal care services, per 15 minutes increase to 84 hours per week. 
The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week. 
The denial is overturned. 

This is an elderly female, with diagnoses that include Alzheimer's disease. It is noted there are issues related to wandering behavior and incontinence of bowel and bladder. The patient has memory deficits but appears capable of casual conversations. The patient's family is involved. The patient was approved for 42 hours of personal care services a week. The request is for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week, which is under review. 

Uniform Assessment System (UAS) notes moderate impairment with decision making regarding Activities of Daily Living (ADLs) such as, when to have meals, clothing choices, dressing, etc. There is a noted decline since the previous assessment. 

The UAS also shows that the patient has difficulty communicating her needs and with comprehension and memory. She requires maximal assistance with medications including compliance, dosage and administration. 

The patient requires extensive assistance and supervision with transfer and mobility, has unsteady gait and uses an assistive device. The patient is also incontinent requiring diapers for urinary and fecal incontinence. 

The patient has difficulty orienting herself to her surroundings and has frequent wandering behavior, attempting to leave her home. 

"Global ageing is becoming severe, and an increasing number of older adults choose to stay in their homes as they age; internationally, the demand for health care in home or community settings has increased. However, safety in home for elderly people is a challenge...Elderly people are at a higher risk of safety related events than younger people due to the natural process of ageing and their health status due to multiple chronic diseases. Unique family situations, regarding the physical environment, caregiver knowledge, application of medical devices and availability of care resources, make home care safety in older adults complicated." (Cao, S. et al. 2021). 

"As for any client, caregivers can assist with Activities of Daily Living (ADLS) and Instrumental Activities of Daily Living (IADLS). The ADLS include help with personal care such as toileting, bathing, dressing and mobility supervision. The IADLS may include everyday tasks such as laundry, meal preparation, light housekeeping, and errands. For clients with dementia, there is also a component of continually managing the behaviors of the disease, such as wandering, agitation, and anxiety, among others...." (Eidschun, A. et al. 2021). 

Based on the above, the insurer's denial must be overturned. 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 home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week services is substantiated.