Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia with delusions, dizziness, intervertebral disc disorders in the lumbosacral region, spinal stenosis in the cervical region, urinary incontinence, and chronic systolic (congestive) heart failure.
Treatment: Personal care aide 7 days x 12 hours x 2 shifts.
The insurer denied coverage for personal care aide 7 days x 12 hours x 2 shifts.
The denial is overturned.

This patient has a history of dementia with delusions, dizziness, intervertebral disc disorders in the lumbosacral region, spinal stenosis in the cervical region, urinary incontinence, and chronic systolic (congestive) heart failure. The Uniform Assessment System (UAS) report showed a significant change in her status and decline in functional abilities. She recently had a right tibial fracture with open reduction and internal fixation (ORIF) after a motor vehicle accident (MVA). She is primarily wheelchair bound and has had repeated falls, confusion and delusions requiring constant supervision. The patient required total dependence with one person assistance in walking, incontinence care, toileting, bathing, dressing, grooming, and with all transfers. Extensive assistance is needed for bed mobility.

Adverse determination states, to approve this service, the following criteria must be met: There must be a documented significant change in your functional status requiring additional time and assistance to complete your instrumental activities of daily living (IADLs).

This patient is completely dependent for care. She needs 24 hour per day, seven day per week care.      

There has been significant change in status and decline in functional abilities. This patient has a very extensive debilitating medical history and is completely dependent. As such, the request is approved.

"Results: After full adjustment, activities of daily living (ADL) limitations differed among older adults with stroke and dementia. Older adults without stroke or dementia had 0.32 [95% confidence interval (CI) 0.29-0.35] ADL limitations compared to 0.64 (95% CI 0.54-0.73) with stroke, 1.36 (95% CI 1.20-1.53) with dementia and 1.84 (95% CI 1.54-2.15) with stroke and dementia. Overall, blacks had 0.27 (95%CI 0.19-0.36) more ADL limitations than whites. Models accounting for stroke led to a 3.7% (95%CI 2.98%-4.43%) reduction in race differences, while those for dementia led to a 29.26% (95%CI 28.53%-29.99%) reduction and the stroke-dementia combination -1.48% (95%CI -2.21% to -0.76) had little impact. Discussion: Older adults with stroke and dementia have greater disability than older adults with either of these conditions alone. However, the amount of disability experienced by older adults with stroke and dementia is less than the sum of the contributions from stroke and dementia. Dementia is likely a key contributor to race differences in disability." (Stamm et al., 2019)

"The Future of Home Health project sought to support transformation of home health and home-based care to meet the needs of patients in the evolving United States health care system. Interviews with key thought leaders and stakeholders resulted in key themes about the future of home health care. By synthesizing this qualitative research, a literature review, case studies, and the themes from a 2014 Institute of Medicine and National Research Council workshop on 'The Future of Home Health Care,' the authors articulate a vision for home-based care and recommend a bold framework for the Medicare-certified home health agency of the future. The authors also identify challenges and recommendations for achievement of this framework." (Landers et al., 2016)

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 aide 7 days x 12 hours x 2 shifts is overturned. Medical Necessity is substantiated.