Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease
Treatment: Personal Care Services, 24 Hours Per Day, 7 Days 
Per Week (split shift) For A Total of 168 Hours Per Week
The insurer denied: Personal Care Services, 24 Hours Per Day, 7 Days Per Week (split shift) For A Total of 168 Hours Per Week
The denial is overturned.

The patient is an elderly female with a history of general debility due to severe Alzheimer's disease. The request was for Personal Care Assistance through Home Health care (Level 2) to be increased from 84 hours per week (12 hours per day, 7 days per week) to 168 hours per week (24 hours per day, 7 days per week, split shift), based on Uniform Assessment System (UAS) of 3 months ago. The health plan denied the request, citing that the patient has a supporting daughter and family who can direct her care. The patient is confused and forgetful. She needs help with cooking, cleaning, laundry, shopping, bathing, dressing, toileting, transferring, walking, personal hygiene, and eating for which the approved hours are adequate. She is bed-bound for which she has a Hoyer lift to help. The helping aide will not help manage her medical conditions as it is outside the scope of the helping aide. The additional hours requested are because of her chronic medical conditions, and to help with her activities of daily living (ADLs) as she is severely cognitively impaired with supervision required at all times, and she is totally dependent for all activities of daily living. A review of the records showed that the patient has multiple chronic medical conditions, including severe Alzheimer's disease, cerebrovascular accident (CVA), hypertension, hypercholesterolemia, deep venous thrombosis (DVT), anxiety disorder, left knee osteoarthritis, and depression. She is bed-bound, non-verbal, and aphasic. Uniform Assessment System-New York (UAS-NY) evaluation of 3 months ago showed that the patient is severely cognitively impaired, with supervision required at all times, and she is totally dependent for all activities of daily living. She lives alone in a two-bedroom apartment on the second floor of a walk-up building and requires 24 steps to navigate in/out of the apartment.

The requested increase in Personal Care Services to 24 Hours Per Day, 7 Days Per Week (split shift) For A Total of 168 Hours Per Week is medically necessary.

The requested increase for Personal Care services from 84 hours per week (12 hours per day, 7 days per week) to 168 hours per week (24 hours per day, 7 days per week) is medically necessary. Based on the most recent Uniform Assessment System (UAS) of 3 months ago, the patient is severely cognitively impaired with supervision required at all times, and she is totally dependent for all activities of daily living. The reason for denial by the health plan as stated in the clinical information above does not align with her disability features as stated in the Uniform Assessment System of 3 months ago as stated above. Therefore, the 168 hours per week (24 hours per day, 7 days per week) based on Uniform Assessment System of 3 months ago requested should be approved. The requested health service is medically necessary.