Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease
Treatment: Consumer Directed Personal Assistance Program (CDPAP) 12 hours/day, 7 days/week, for a total of 84 hours/week.
The health plan denied CDPAP 12 hours/day, 7 days/week, for a total of 84 hours/week.
The determination is overturned.

The patient is a female with medical history notable for dementia, incontinence, and ambulatory dysfunction. The patient's neurologist provided a letter of support for this appeal. The letter states that the patient's dementia has been worsening, and she has had a rapid decline. She is now totally dependent on others for her activities of daily living (ADLs). She has had multiple falls due to instability and cannot walk without assistance. The physician feels that her current allotment of home health hours is insufficient to meet her current requirements for personal care assistance.

The patient's daughter provided a letter of support for this appeal. The letter states that her mother is "in desperate need of more home care hours." The patient lives with her husband who also suffers from dementia and memory issues. They have very limited informal assistance. The patient cannot eat, dress, or shower without assistance. She ambulates with a cane or walker but still requires hands on assistance for support. She cannot use the bathroom independently and does not realize when she needs to urinate or defecate; she does wear diapers and needs assistance with management. She needs assistance with transfers.

A Uniform Assessment System (UAS) was completed and was available for review. The patient lives in an apartment with her spouse. She was alert and oriented to person only. She has episodes of confusion and forgetfulness, as well as daily episodes of hallucinations. She is not able to direct her own care. She requires total dependence for essentially all instrumental activities of daily living (IADLs). For her ADLs, she requires maximal assistance for bathing, hygiene, dressing, toilet transfer, and toilet use. She requires extensive assistance for walking, locomotion, bed mobility, and eating. She is incontinent of urine with no control present; the report states she is continent of stool, which is contradicted elsewhere. A task tool recommended 8 hours/day to address her personal care needs. Compared to a prior assessment, she showed a decline across numerous functional domains.

At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP) 12 hours/day, 7 days/week, for a total of 84 hours/week.

The health plan's determination of medical necessity is overturned in whole.

The requested health service of CDPAP 12 hours/day, 7 days/week, for a total of 84 hours/week is medically necessary for this patient.

The patient has advanced dementia, ambulatory dysfunction, and incontinence. She cannot perform any IADLs or ADLs without personal assistance. Her personal care needs are expected to be continuous and unscheduled in nature. Her current allotment of 5 hours/day is insufficient to meet her needs, as testified by her treating physician. It is also below the recommended allowance from the tasking tool, which itself may even underrepresent the patient's true need based on the unscheduled nature of her personal care requirements.