Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia

Treatment: 84 hours per week, Consumer Directed Personal Assistance Services (CDPAS)

The insurer denied coverage for 84 hours per week, Consumer Directed Personal Assistance Services

The denial is overturned

This patient is a female with several chronic medical conditions associated with functional impairment which is reported by the patient's physician and daughter as significantly worse over the past year. The patient lives alone. Her daughter is the primary informal caregiver. It is noted that the daughter lives in the same building as her mother. The patient receives personal care services as Consumer Directed Personal Assistance Services.  She was receiving 30 hours per week. The most recent Uniform Assessment System (UAS) provided for review. The UAS functional status report indicated the patient is totally dependent or needs maximal assistance for most Instrumental Activities of Daily Living (IADLs), except stairs and transportation (extensive assistance). The patient needs extensive assistance for most Activities of Daily Living (ADLs), except upper body dressing, personal hygiene, bed mobility (limited assistance) and eating (supervision). 

The patient has dementia with probable diagnosis of Alzheimer's disease.  The patient has multiple signs of significant cognitive impairment, including: impaired decision making; disoriented; memory worse over the past year. Visual hallucinations patient has some difficulty finding words; needs repetition to follow a conversation (patient is deaf from birth; communication is with sign language). She has left the water running and the stove on. The neurologist recommended starting Aricept (donepezil), which is indicated for treatment of cognitive impairment due to certain types of dementia. The patient has physical impairments that limit her ability for most ADLs; but her cognitive deficits also affect her ADLs. Impaired memory and poor judgment/safety awareness during ADLs increase risk of falls and household accidents. Providing assistance and supervision/ cues for safety during ADL care is necessary, and is part of the scope of practice for personal care services.

The patient has chronic pain, specifically in her knees and back. The patient has osteoarthritis of her knees which affects all weight-bearing activities, including standing, walking, transfers, and affects the ability to perform various household tasks. Knee pain is probably a significant factor causing her unsteady gait. She needs a cane or walker and assistance for ambulation. Knee pain adversely affects ADLs such as bathing, lower body dressing, toileting, transfers (UAS noted patient needs assistance to transfer from sitting to standing position). For toileting, the patient has difficulty reaching behind her back, raising the possibility that the patient may have pain and/or limited range of motion of her shoulder which can affect other ADLs dependent on upper extremity function.  
The patient has back pain that affects various activities including walking, transfers bending, bathing, lower body dressing, toileting, and various housekeeping tasks.

The patient also has urinary incontinence.  She takes diuretics daily, which increases urinary frequency. Inadequate incontinence care can result in incontinence associated skin damage (e.g. fungal infection, dermatitis). It is in the patient's best interest to have a caregiver present throughout the day to provide assistance to ensure toileting is done safely and with adequate hygiene; and that incontinence care in provided in a timely manner when needed.

The patient is totally dependent on caregivers for meal preparation and night toileting/incontinence care. Informal caregiver is not available to assist the patient for this amount of time (12 hours per day). When informal caregivers are not available to provide support for daily activities, then personal care services are indicated to provide necessary assistance for IADLs and ADLs when needed throughout the day. 

The patient needs substantial assistance for all daily activities in her home from morning until she goes to bed at night and may need some assistance during the night. CDPAS 84 hours per week will provide aide services during day and early evening hours (12 hours per day); with additional support from the daughter during the other 12 hours of the day.  
Consumer Directed Personal Assistance Services 84 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for 84 hours per week, Consumer Directed Personal Assistance Services (CDPAS) is reversed. Medical necessity is substantiated.