Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease.
Treatment: Consumer Directed Personal Assistance Services (CDPAS) of 12 hours per day at 7 days per week.

The insurer denied coverage for CDPAS of 12 hours per day at 7 days per week.  The denial is overturned

The patient is a female with Alzheimer's disease for at least 9-10 years and has progressed to advanced stage. The patient needs assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs).  The patient lives at home with alternating two-week around-the-clock shifts by an aide and her daughter. 

The patient needs assistance to get out of bed in the morning and into bed at night. For toileting she needs assistance with pullups, wiping and cleaning hands (toileting over the 3 days occurred 3-6 times per day between 8am and 9pm). Medications are given in the morning and evening. Patient is assisted with daily walk. All meals were prepared by caregiver. Assistance was provided with meals, including cues, cutting up food.  Assistance was provided with dressing, personal hygiene, and shower. Patient needs direction and reminders at times for location of kitchen and bathroom. A few behavioral issues occurred, e.g. patient refused to get off toilet; refused to prepare for bed; refusal of medication, agitated.

The patient has Alzheimer's disease for many years.  Neurology notes indicate earlier stage of dementia, with some memory loss; patient was taking Aricept. The neurologist's notes over several years describe the patient's progressive cognitive decline, and various behavioral problems that have occurred. Assessment of cognition indicates substantial cognitive impairment, including: oriented to person; short term and procedural memory impairment; decision making for daily tasks are consistently poor/unsafe. The patient is confused, easily distracted. Her communication skills are significantly impaired, noted as limited to concrete requests, and she responds mostly to simple direct communication only.

The patient has physical impairments that probably limit her ability to perform ADLs, but it is likely that cognitive impairment has contributed to her functional decline with ADLs. In later stages of dementia the affected person may not remember, recognize or know what to do for basic daily activities. For example, the physical therapist noted that the patient is very forgetful, but even with prompts and cues she requires help with eating and toileting (e.g. using utensils, using toilet paper). Impaired memory and poor judgment affect safety during ADLs and can increase risk of falls and household accidents. Providing supervision, cues and/or assistance when needed for safety during ADLs is part of the scope of care provided by personal care services. 

Documentation provided support the patient's need for assistance with ADLs at various times throughout the day from the time she gets out of bed in the morning until she goes to bed at night, which is a 12 hour time span. Therefore, it is medically necessary for a caregiver to provide assistance during the hours of the patient's daytime activity (12 hours per day) to ensure effective and safe performance of all daily activities. 

Consumer Directed Personal Assistance Services 7 days per week, 12 hours per day, 84 hours per week are medically necessary. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance Services (CDPAS) of 12 hours per day at 7 days per week is reversed. Medical necessity is substantiated.