Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia, Osteoarthritis.
Treatment:  Consumer and Self Directed Personal Assistance Services 24 hours a day, 7 days a week (split-shift).

The insurer denied the Consumer and Self Directed Personal Assistance Services 24 hours a day, 7 days a week (split-shift).  The denial was overturned.

This is a female patient, who lives alone in apartment on second floor of nephew's house.  The patient has a history of dementia, anxiety, hypertension, type 2 diabetes, hypothyroidism, bilateral osteoarthritis of knee, history of falling, functional urinary incontinence, fecal incontinence, insomnia.  Her medical conditions have adversely affect her cognitive and physical function.  She needs assistance with all IADLs and most ADLs. She has been receiving Consumer Directed Personal Assistance Services (CDPAS) 10 hours per day (70 hours per week).  The patient's nephew requested increase of CDPAS to 24 hours per day, 7 days per week split shift; request was denied by the insurer.  An external appeal was requested. 

The patient has Alzheimer's disease.  There are no formal cognitive evaluations or neurology notes available for review; but the description of the patient's mental status and behavior as noted in the UAS and physician's records provides some information about the patient's cognitive status (with information reported by the family to UAS nurse and physician).  The patient is oriented x 1; she has impaired decision making capacity (decisions consistently poor/unsafe); and extensive memory impairment (short term, procedural, situational).  Confusion is noted as getting worse.  She does not sleep well and is often up at night and walks through the house.  The family reports patient has had multiple falls when alone.  There are stairs in the house (patient lives on second floor).  It appears that there is a stair lift, but patient does not use it.  She resists care and is verbally abusive at times.

For a person with dementia, decline in ability to perform daily activities is an expected consequence of the disease as it progresses.  Performance of IADLs usually declines before ADLs; as IADLs generally require a higher level of cognitive function. In later stages of dementia, the affected person eventually loses the ability to perform basic activities of daily living (ADLs).  It is likely the patient's need for assistance with IADLs is at least partly due to cognitive impairment. The effect of dementia on her ADL function is less clear, but cognitive decline probably has a negative impact on her ability with ADLs.

The patient has osteoarthritis affecting both knees, with intermittent knee pain.  It is noted she has poor balance, unsteady gait, and is unable to tolerate prolonged standing and walking.  It is also noted she has limited range of motion (ROM) (specific joints not identified).  Arthritis is a frequent cause of pain and disability in older people.  As dementia progresses and communication skills decline, the affected person may not be able to clearly report pain with verbal communication.  Pain may be expressed in various ways, such as behavioral changes (e.g. agitation) or change in sleep (e.g. increased restlessness). 

The patient has several medical conditions contributing to significant physical and cognitive impairment.  The patient needs assistance with most daily activities.  The combined effects of physical limitations and cognitive deficits place the patient at risk for adverse health and safety events.  It is medically necessary for the patient to have a caregiver present to provide assistance with daily activities, including ADLs that occur at various and unscheduled times during the day and night.

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

The medical necessity for Consumer and Self Directed Personal Assistance Services 24 hours a day, 7 days a week (split-shift) is substantiated.  The insurer's denial is overturned.