Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Worker (PCW) services 5 days per week, 24 hours per day (Monday to Friday) and Consumer Directed Personal Assistance services (CDPAS) 2 days per week, 24 hours per day (Saturday and Sunday), continuous care by more than 1 person; 168 hours per week.

The insurer denied coverage for Personal Care Worker (PCW) services 5 days per week, 24 hours per day (Monday to Friday) and Consumer Directed Personal Assistance services (CDPAS) 2 days per week, 24 hours per day (Saturday and Sunday), continuous care by more than 1 person; 168 hours per week.

The denial is overturned.

This case is regarding coverage for an increase in personal care worker hours.  An assessment was conducted noting that the patient lives alone in a private dwelling on the fifth floor of a building with elevator access.  The environment is free from safety hazards.  The report stated the patient was moderately impaired in terms of cognitive skills for daily decision-making.  The patient had noted memory problems with a decline in their overall decision-making skills as compared to 90 days prior.  The patient had some difficulty with communication and had minimal difficulty with hearing.  The patient has a history of dementia with wandering reported in the last 3 days.  The patient had opened the door to the closet, thinking this was the bathroom.  Cameras were installed in the home with wandering precautions in place.  The patient required maximal assistance with meal preparation, total dependence for ordinary housework, managing finances, extensive assistance with managing medications, and required maximal assistance for phone use.  The patient needed maximal assistance with navigating stairs and was totally dependent for shopping.  The patient needed maximal assistance for transportation and equipment management, and required extensive assistance with bathing, personal hygiene, dressing the upper and lower body, walking, locomotion, and toileting transfers.  The patient required maximal assistance for toileting use as well as eating, with limited assistance needed for bed mobility.  The patient walked using an assistive device.  The patient had a decline in their overall activities of daily living status as compared to 90 days prior.  The patient had an overall deterioration in self-sufficiency as compared to 90 days prior.  The patient was observed using a rolling walker and has a hospital bed with no bed rails present.  The patient was frequently incontinent for bladder control with infrequent incontinence for bowel control.  The patient was diagnosed with dementia other than Alzheimer disease and had a history of stroke/cerebrovascular access (CVA).  The patient also had a history of coronary heart disease and congestive heart failure along with depression.  The patient had 2 falls reported between 31- and 90-days prior with reports of minor injuries.  The patient had balance issues associated with dizziness and an unsteady gait.  The patient also reported some chest pain on one of the last 3 days and was exhibiting delusions on one of the last 3 days.  The patient had a history of acid reflux and constipation as well as sleep problems.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for increased Personal Care Worker (PCW) services from 5 days per week, 9 hours per day (Monday to Friday) and Consumer Directed Personal Assistance services (CDPAS), 2 days per week, 9 hours per day (Saturday and Sunday); 63 hours per week, to Personal Care Worker (PCW) services 5 days per week, 24 hours per day (Monday to Friday) and Consumer Directed Personal Assistance services (CDPAS) 2 days per week, 24 hours per day (Saturday and Sunday), continuous care by more than 1 person; 168 hours per week is substantiated.