Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia. 
Treatment: Increase Consumer Directed Personal Assistance From 45.5 Hours Per Week, To 7 Days per Week, 24 Hours per Day, 168 Hours Per Week Continuous Care by more than one person. 

The insurer denied the Increase Consumer Directed Personal Assistance From 45.5 Hours Per Week, To 7 Days per Week, 24 Hours per Day, 168 Hours Per Week with continuous care by more than one person. 

The denial is overturned. 

This male patient has conditions including Alzheimer's dementia.  He is appealing denial of increase in consumer directed personal assistance (CDPAS) from 45.5 hours per week to 168 hours per week.  The health plan approved increase to 63 hours per week.  

Uniform Assessment System (UAS) evaluation completed shows moderating impaired cognition and functional status: maximal assistance with bathing, personal hygiene, dressing, locomotion, and toilet use; and extensive assistance with eating. He has bowel and bladder incontinence. Modes of locomotion include wheelchair and scooter.  A statement notes the patient has several chronic conditions, including progressive dementia.  The statement notes the patient lives from bed to wheelchair.  He requires assistance with all activities of daily living (ADLs).  He needs turning/repositioning every two to three hours to prevent bedsores and skin breakdown.  The statement notes the patient does not sleep soundly through the night and requires the caretaker when he awakes.  He has unscheduled needs and he is unsafe to be left alone.  A letter from the provider notes the patient is unable to transfer, stand or walk without maximal/total assistance.  He requires total assistance with all activities of daily living, including incontinence care and bed turning every two to three hours. 

Yes, the proposed treatment is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  This patient has several chronic conditions including Alzheimer's dementia.  He is appealing denial of increase consumer directed personal assistance (CDPAS) from 45.5 hours per week to 168 hours per week.  The health plan approved an increase to 63 hours per week. 

Per the Uniform Assessment System (UAS) evaluation completed, the patient requires maximal assistance with all activities of daily living, except extensive assistance with eating.  He has bowel and bladder incontinence.  Appeal statements note the patient has progressive dementia.  He is bed and wheelchair bound.  He requires assistance with all activities of daily living, including turning/repositioning every two to three hours.  This patient has significant cognitive and physical impairments that are progressive.  He requires assistance throughout the day and night with activities of daily living and turning/repositioning.  The approved consumer directed personal assistance services (CDPAS) 63 hours per week is inadequate to meet the patient's needs for assistance with activities of daily living (ADLs) / instrumental activities of daily living (IADLs).  The proposed increase in consumer directed personal assistance services (CDPAS) to a total 168 per week is medically necessary and appropriate to meets this patient's needs. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.