Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia

Treatment: Personal care services 12 hours a day, 7 days a week

The insurer denied coverage for personal care services 12 hours a day, 7 days a week.

The denial is overturned.

This is patient with chronic medical problems including hypertension, kidney disease and dementia.  The patient lives alone in a 1 bedroom apartment.  The insurer approved personal care services (PCS) 5 hours/day, 6 days/week and 6 hours/day, 1 day/week (total 36 hours).  The request is for PCS 12 hours/day, 7 days/week (84 hours total), which was denied by the insurer, leading to an external review.   

The Uniform Assessment System (UAS) finalized report was reviewed.  The patient's cognitive skills are described as moderately impaired.  The patient reportedly requires maximal assistance for completing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires extensive assistance for bathing, personal hygiene, dressing, bed mobility and toilet transfer/use.  Limited assistance is reportedly needed for locomotion and ambulation.  The patient reportedly requires supervision with eating.  The patient is reportedly incontinent of bladder and bowel.  The patient's activities of daily living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days.  There have been no reported falls over the prior 90 days.  

Submitted for review is an "advocacy letter" from the patient's social worker to their treating physician requesting additional personal care services.  The social worker indicated "Daughter asking for 12 hours/7 days."  The patient's treating physician submitted a letter indicating the patient's current personal care services are "inadequate to meet their needs because they do not take into account the patient's diminished functional status and progressing Alzheimer's dementia."  The most recent treatment note from the patient's provider (in addition to prior clinical documents) was reviewed.  There is no documented specific functional assessment.  However, the provider notes the patient has a "normal gait" and there are no neurological "focal deficits."   A prior note from the patient's provider notes a "slow shuffling gait, requires support from daughter."  However, at that time, the patient had recently sustained a left ankle injury secondary to a syncopal episode (as documented in the hospital discharge summery note) that was "improving" and home physical therapy was recommended. 

The patient's medical condition, physical limitations and functional ability are at the level or unpredictable as to require the requested 84 hours of PCS.  The clinical records reviewed are consistent with the patient having cognitive and physical impairments that warrant increasing PCS.  Based on the records reviewed as discussed above, attention to the patient's health and safety can be more appropriately provided and maintained by increasing PCS to 12 hours/day, 7 days/week, totaling 84 hours/week.

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 personal care services 12 hours a day, 7 days a week is substantiated.