Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: 24 Hours Per Day, 5 Days Per Week (live-in) Personal Care Services, Level 2 and 24 Hours Per Day, 2 Days Per Week (live-in), Consumer Directed Personal Assistance Services (CDPAS) Level 2. Combined Total 24 Hours Per Day, 7 Days per Week (live-in) Consumer Directed Personal Assistant Services Level 2
The insurer denied: 24 Hours Per Day, 5 Days Per Week (live-in) Personal Care Services, Level 2 and 24 Hours Per Day, 2 Days Per Week (live-in), Consumer Directed Personal Assistance Services (CDPAS) Level 2. Combined Total 24 Hours Per Day, 7 Days per Week (live-in) Consumer Directed Personal Assistant Services Level 2
The denial is overturned.

The patient is an adult female with dementia and multiple other listed conditions, including the following: Atherosclerotic heart diseases; Chronic fatigue, unspecified; Constipation, unspecified; Difficulty in walking, not elsewhere classified; Dizziness and giddiness; Essential (primary) hypertension; Folate deficiency anemia, unspecified; Gastro-esophageal reflux disease without esophagitis; Hyperlipidemia, unspecified; Hypothyroidism, unspecified; Insomnia, unspecified. In addition, it is reported that the patient has mental health issues related to her being a Holocaust survivor, and she is fearful of living alone. Three months ago, the Comprehensive Community Health Assessment Report noted the following:
Oriented x 2-3 
Total dependence on meal preparation and ordinary housework.
Extensive assistance with medications.
Maximal assistance with stairs.
Total dependence on shopping.
Maximal assistance with transportation.
Maximal assistance with bathing and lower body dressing.
Extensive assistance with personal hygiene and upper body dressing, walking, locomotion, toileting.
Reported episodes of anxiety and panic attacks at nighttime and patient calling family members.
Last month, the Comprehensive Community Health Assessment Report noted the following:
The patient is A&O (alert an oriented) x2, disoriented to time, forgetful at times, and unable to recall DOB (date of birth). Her short-term and procedural memory is impaired. Her situational memory is intact. Supervision is necessary in specific situations.
The patient has declined with ADL (activities of daily living).
The patient has deteriorated in self-efficiency.
The patient is frequently incontinent. She is instructed to use toilet every 2-3 hours to avoid incontinence.
Unsteady gait was exhibited in all of the prior 3 days.
The patient was reported to have experience a fall at home about two weeks prior. The patient's daughter writes in an undated letter that the patient has dementia and is very confused during the time she is by herself late evening, at night, and early morning. When her aide leaves, she cannot get out of her chair, walk around the apartment, get dressed, or get medications and food. She needs someone to put her in bed, change her diapers, and give her medications, water, and snacks. She was falling at night, because of limited range of motion and strength in the lower and upper body. Hip surgery, arthritis, and high blood pressure make it difficult to walk, and weakness in her hands does not allow hold medications, walker, and other objects. The patient's family support is very limited. She does not have a family member available to consistently help her. The provider notes that the patient is unable to be left alone, as she might potentially leave gas on the stove and attempt to leave home, which will put her and others at risk of harm. Her dementia is progressing, and the patient is unsafe to be left alone at any time of the day and night. Compared with the prior examination, the examination last month showed that the patient had a decline in ADL (activities of daily living) and a deterioration in self-efficiency. 

The requested health service is medically necessary.

Overall, the review of records supports a decline in the patient's functions manifesting as falls. Her needs for assistance at night go beyond primary fall prevention or for aide assistance "for safety and supervision" as her needs/activities (such as toileting every 2-3 hours, need for medication, and transfers and locomotion that require extensive-to-maximal assistance) extend through the night. Her impaired short-term memory and reported mental health issues only exacerbate the need for increased hours.