Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: 
The insurer denied consumer directed personal assistance 12 hours per day 7 days per week (Monday through Sunday) a total of 84 hours per week.
The determination is consumer directed personal assistance 12 hours per day 7 days per week (Monday through Sunday) a total of 84 hours per week.


This is a female patient with a medical history notable for dementia, diabetes, hypertension, and osteoporosis. She is currently receiving 21 hours per week of consumer directed personal assistance. The patient and her care team requested an increase in consumer directed personal assistance to 12 hours per day, 7 days per week (total 84 hours per week). This request was denied by the insurance company, and the denial is the subject under review.
A letter of support for this appeal was filed by the patient's long term primary care physician. The letter states that she was doing well living at home with minimal assistance until this past year when she began to develop dementia. The physician reports that she now relies on others for basic daily living needs. He reports that she relies on others for mobility even with use of a walker. She wears adult diapers to help with incontinence and still relies on outside help to manage her incontinence. The physician recommended an increase in home health services to address these functional needs which are not currently being met.
A letter of support for this appeal was provided by the patient's case worker. This letter reports that the patient needs more assistance with functional activities due to her recent decline. She has been working closely with her physician for some time to optimize her medically, but they report that there is little more that can be done and she needs the support of additional aide hours.
A Mini-Mental State Examination (MMSE) was performed. The result was 16/30, which is consistent with possible moderate cognitive impairment. This was a decrease from a prior score of 20/30.
A Uniform Assessment System (UAS) was completed. This was the most recent evaluation and it was completed via teleconference. Cognition was moderated impaired, with decisions consistently poor or unsafe. She was alert and oriented to person and place only. She was unable to self-direct her care with episodes of forgetfulness. From a functional standpoint, she requires total dependence for housework. She requires maximal assistance for managing finances and medications, meal preparation, shopping, and transportation. She requires extensive assistance for stairs and phone use. For her activities of daily living (ADLs), she requires maximal assistance for dressing lower body. She requires extensive assistance for bathing, hygiene, dressing upper body, walking, and locomotion. She requires limited assistance for toilet transfer, toilet use, and eating. She is independent with bed mobility. She is frequently incontinent of urine (daily) and infrequently incontinent of stool. She uses adult diapers. The report notes that the patient is afraid to use the bathroom by herself. Compared with a prior Uniform Assessment System (UAS) performed, she showed a decline in the following domains: cognition, continence, housework, managing finances and medications, dressing upper / lower body, hygiene, walking, locomotion, toilet transfer, and eating. A task tool associated with the most recent assessment recommended 28.79 hours per week for her personal care needs, which is actually a decrease from the 32.13 hours per week recommended at the time of the assessment. At issue is the medical necessity of consumer directed personal assistance 12 hours per day 7 days per week (Monday through Sunday) a total of 84 hours per week. 

The requested health service/treatment of consumer directed personal assistance 12 hours per day 7 days per week (Monday through Sunday) a total of 84 hours per week is medically necessary for this patient.
The patient has had a marked decline in cognition, functional status, and continence over the past year. She now requires human assistance for nearly all functional needs. She is not able to direct her care due to her dementia. She has incontinence of urine daily and needs assistance with toileting. 3 hours per day is not sufficient to meet the functional needs of a person with this combination of health problems. Because her needs cannot be scheduled and predicted, a task tool cannot be relied on to accurately determine the number of personal aide hours. Her physician attested that she has had a decline and requires additional assistance to help with activities of daily living. Given her decline in status it is medically necessary to increase her personal assistance hours to meet her functional needs. These hours are not for safety monitoring and security alone, but to address the personal care needs of the patient.