Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease

Treatment: 12 additional home health aide (HHA) hours for overnight (for a total 20 hours/day x 7 days a week)

The insurer denied coverage for 12 additional home health aide (HHA) hours for overnight (for a total 20 hours/day x 7 days a week).

The denial is overturned. 

This is a female patient who requires substantial assistance for all her daily activities due to functional decline. The patient has Alzheimer's disease and has a decline in her ability to perform daily activities. The patient lives at home with her husband. The patient receives personal care services with home health aide (HHA) 8 hours per day, 56 hours per week. Her husband is the primary informal caregiver and it appears he is responsible for the patient's care after the HHA leaves each day. Concern was raised that the patient's care needs may be more than the husband can manage when the aide is not present. Request was made for additional 12 HHA hours per day (total of 20 hours per day). The patient advocate's report identified a 4-hour community program each day (run by the insurer) that provides some type of services (details are not provided), which appears to be the reason for the request for HHA 20 (instead of 24) hours per day.
	
The Uniform Assessment System (UAS) report indicates that the patient is totally dependent for all instrumental activities of daily living (IADLs), except transportation is noted as maximal assistance. For activities of daily living (ADLs), the patient needs maximal or extensive assistance or total dependence for most ADLs, except walking, locomotion, eating (limited assistance). Considering the patient's medical condition and functional status, medical records and nighttime activity log, it is apparent that the patient needs assistance for all daily activities. Therefore, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day and night to provide assistance for all daily activities when needed. The patient needs assistance for daily activities that occur at various scheduled and unscheduled times throughout the day and night. This includes routine household tasks and other IADLs; routine morning and evening ADLs, such as bathing, dressing, personal hygiene; meals and snacks to ensure adequate and safe food and fluid intake; all toileting and incontinence related tasks; out-of-bed mobility (transfers, walking) and periodic repositioning in bed for pressure relief. Without adequate assistance, the patient is at risk for significant adverse events, including falls/injuries, malnutrition, dehydration, skin injury. 

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. The family (via the patient advocate) requested increase of HHA services to 20 hours per day. It is reasonable to conclude that neither the patient's husband, nor any other informal caregivers can continue to provide assistance to the patient for extended periods of time on a daily basis. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide assistance for daily activities when needed throughout the day and night. The records provided for review support medical necessity for caregiver assistance with ADLs at various and unpredictable times throughout the day and night. The best option to provide care for the patient at this advanced stage of functional impairment is to provide the requested 20 hours split shift to ensure proper assistance is available when needed. 

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

Based on the above, the medical necessity for 12 additional home health aide (HHA) hours for overnight (for a total 20 hours/day x 7 days a week) is substantiated. The insurer's denial should be overturned.