Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, dementia, aphasia and generalized weakness. 

Treatment: Increase in Consumer Directed Personal Assistance Services to 24 Hours Per Day (live-in) (Health plan approved 63 hours/week). 

The insurer denied the Increase in Consumer Directed Personal Assistance Services to 24 Hours Per Day (live-in) (Health plan approved 63 hours/week). 

The denial is overturned. 

The patient is a female. Her medical conditions include Alzheimer's disease, dementia, aphasia and generalized weakness.  She lives alone.  The denial of increase in Consumer Directed Personal Assistance Services to 24 hours per day, live-in, is being appealed. The health plan approved 63 hours per week. 

UAS (Uniform Assessment System) evaluation completed shows moderately impaired cognition and functional status:  total dependence with meal preparation, housework, managing finances and medications, phone use, and shopping; maximal assistance with bathing, personal hygiene, dressing, and toilet use; extensive assistance with toilet transfer, bed mobility and eating; and limited assistance with walking and locomotion.  She is incontinent of bowel and bladder.  Compared to UAS (Uniform Assessment System) evaluation completed previously, cognition was reported as severely impaired and functional status showed extensive assistance with bathing, personal hygiene, dressing, and toilet use. 

An appeal letter notes the patient needs assistance with all ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation.  It notes that the patient's dementia has progressed causing impaired speech and communication.  Her daughter, who assists with care, will be returning to work.  An appeal statement notes the patient has progressive dementia and needs full time care because she is unsafe to be alone for extended periods.  Another appeal statement notes there has been a decline in the ability to perform ADLs (activities of daily living), including increased incontinence.  It notes the patient needs frequent diaper changes during day and night.  It further notes the patient is unable to transition without assistance, and the patient is unable to call for help due to aphasia. 

Yes, the Increase in Consumer Directed Personal Assistance Services to 24 Hours Per Day (live-in) is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase in Consumer Directed Personal Assistance Services to 24 hours per day, live-in is being appealed.  The health plan approved 63 hours per week. 

This patient has multiple chronic conditions including dementia, aphasia, and generalized weakness.  UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs and personal care needs.  Compared to UAS (Uniform Assessment System) evaluation completed previously, the patient's functional needs have increased from extensive to maximal with bathing, personal hygiene, dressing, and toilet use.  She is incontinent of bowel and bladder.  Appeal states note there has been a decline in the patient's functioning.  She is unable to transition without assistance.  Due to aphasia, she is unable to call for assistance.  The patient will no longer receive informal support from her daughter.  This patient has significant needs, including assistance with toileting and transition, which occur during both day and night.  These needs cannot be met with the approved 63 hours per week.  Based on her medical condition and the progression, the requested increase in Consumer Directed Personal Assistance Services to 24 hours per day, live-in, is medically necessary to meet this patient's needs for assistance as noted above.