Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's Dementia.
Treatment:  Personal care assistance services, a total of 117 hours per week.

The insurer denied Personal care assistance services, a total of 117 hours per week.  The determination is overturned.

The patient has a medical history notable for Alzheimer's dementia, prior cerebrovascular accidents, and gait difficulty. The patient is approved for 95 hours per week of personal care assistance services (19 hours per day, 5 days per week; no hours on the weekend; informal support provided by the patient's daughter between shifts). The patient and his care team requested an increase to 117 hours per week (to add in 11-hour per night overnight coverage on the weekends), and this request was denied by the health plan.

A letter of advocacy was provided for this review. The letter states that the patient's daughter has provided informal support to the patient during the hours that the patient does not have a home health aide, including for 24-hour coverage over the weekend. She is unable to continue to do so, and therefore, the letter states that adequate personal care should be provided.

A letter of support for this appeal was provided by the patient's neurologist. The letter states that he needs constant support for his activities of daily living. He is unable to perform these tasks himself, and due to his dementia does not remember or understand how to direct his care.

A Uniform Assessment System (UAS) was performed and was available for review. The patient was alert and oriented to person only. He was not self-directing and unable to verbalize his needs. From a functional standpoint, he requires total dependence for housework and shopping. He requires maximal assistance for meal preparation, managing finances and medications, phone use, and transportation. For his activities of daily living (ADLs), he requires extensive assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. He requires limited assistance for hygiene, dressing upper body, and bed mobility. He is frequently incontinent of urine and continent of stool; he uses pull-ups for incontinence care.

Night logs for personal care were provided for review. They demonstrate that the patient has personal care needs throughout the night. He periodically has wet pullups requiring not only a change but also a change in linens and clean up. Other times, he does not have incontinence but still requires assistance to urinate with a urinal. The frequency of personal care overnight ranges from every 2-5 hours. At issue is the medical necessity of personal care assistance services, a total of 117 hours per week.

The requested health service of personal care assistance services, a total of 117 hours per week is medically necessary for this patient.

The patient has advanced dementia and is unable to direct his own care. He is incontinent of urine and cannot change his own pullups in the event of incontinence. He requires continuous personal care to attend to his unscheduled functional needs. The health plan already approved overnight care for him 5 days per week, recognizing this need for the patient. He has been receiving informal support from his daughter, but she is no longer able to provide 24-hour care on the weekends. Given that he requires assistance overnight the other nights of the week, he would also require assistance on the weekends. If his daughter is not able to provide this informal support, it is medically necessary for a personal care aide for the weekend night shift as well. If his toileting needs are not addressed, it could result in skin breakdown and/or infection.