Appeal type: Medical necessity
Decision: Overturned

Diagnosis: stroke, aphasia, Alzheimer's disease, diabetes mellitus, hypertension, glaucoma, hyperlipidemia, recent sepsis, deep vein thrombosis (DVT) and coronavirus disease (COVID).

Treatment: Personal Care Worker (PCW) services 7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person.

The insurer denied coverage for PCW services 7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person.

The denial is overturned.

This female has a diagnosis of Alzheimer's disease with cognitive decline. She suffered a hemorrhagic stroke and her condition worsened to the point of requiring maximal assistance for personal care needs. She also has diabetes, hypertension, glaucoma, recent sepsis, DVT (deep vein thrombosis), and COVID (coronavirus disease). She has limited supports. 
  
The Department of Health reports that personal care services help people with everyday tasks including activities of daily living (ADL's) or household tasks. It also states that personal care attends to the physical needs of people disabled or otherwise unable to take care of themselves. The American Psychiatric Association (APA) Practice Guideline for The Treatment of Patients with Alzheimer's Disease and Other Dementias reports that choice of specific treatments for a patient with dementia begins with the establishment of a specific diagnosis and an assessment of the symptoms being experienced by that patient. A multimodal approach is often used, combining, for instance, behavioral and psychopharmacological interventions as available and appropriate. At the end of life, many patients with dementia are cared for in a hospice program. It also is reported that patients with dementias may benefit more from consistency, reminders, and familiarity in the environment. Also, according to Ghosh R., a number of general environmental and behavioral management principles can optimize safety, enhance function, and thus delay hospitalization. Familiar surroundings, simple and constant daily routines, door locks to prevent wandering, protection against hot stove surfaces and toxic substances and avoidance of driving are all important safety measures. Changes in the environment may worsen confusion and agitation. In dementia patients it is important that they have a familiar environment as they have cognitive decline, paranoid ideation, forgetfulness and being in a non-familiar environment is worse for the patient as a result. In this case this patient required more direct personal care services as she needed more supervision for safety in the home and to help more with ADL's. 

This patient had a hemorrhagic stroke and her condition worsened to the point of requiring maximal assistance for personal care needs. According to a home visit note, her condition deteriorated following a hospital discharge. She was bedbound, had stage 2 sacral decubitus requiring turning every 2 hours, bowel, and bladder incontinence. She is dependent for all ADL's including bathing, personal hygiene, dressing, meal preparation, managing finances and medications, housework, phone use, navigating stairs, shopping, transportation, transfers, ambulating, and bed mobility. She also had unscheduled frequent nighttime needs. She had cognitive impairment due to Alzheimer's dementia. She required cues and prompting for all ADL's and needed reminders to eat. Her functioning was severely impaired and required full time personal care worker services. She was unable to care for her basic needs and required more supervision in the form of 168 hours per week of PCW services which was an increase from the 91 hour per week she was getting. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Personal Care Worker (PCW) services 7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person is reversed. Medical Necessity is substantiated.