Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: increase personal care aide hours from 7 days a week, 10 hours (hrs) a day to 7 days per week live-in. 
The insurer denied increase personal care aide hours from 7 days a week, 10 hrs a day to 7 days per week live-in. 
The determination is overturned. 

This is a female patient with a medical history notable for coronary artery disease, incontinence, and dementia. The patient is approved for 10 hours per day, 7 days per week for a total of 70 hours per week of personal care assistance. The patient and her care team requested an increase to 7 days per week live in. 
A community advocate provided a letter of support. The letter states that the patient suffers from Alzheimer's dementia which complicates all aspects of her care. 
The patient's nurse practitioner provided a letter of support. The letter states that the patient is of advanced age and suffers from age-related debilities and cognitive decline which have been rapidly deteriorating. The patient is unable to ambulate without assistance. She has urinary incontinence and requires assistance with multiple daytime and night time changes of soiled diapers. She requires assistance with all activities of daily living including repositioning in bed. The provider recommends 24-hour home care for the patient. 
The patient's physician provided a letter of support. The letter states that the patient's condition has been deteriorating since the death of her husband. She cannot transfer or ambulate without assistance. She has had multiple episodes of falling. She needs assistance with using the bathroom. 
A Uniform Assessment System was completed. The patient lives alone in an apartment. She was oriented to person and place but disoriented to time. She has started to experience sundowning. For her instrumental activities of daily living, the patient requires total dependence for meal preparation, how to cook, and shopping. She requires maximal assistance for transportation, stairs, finances, and medications. For her activities of daily living, she requires maximal assistance for dressing lower body and toilet use. She requires extensive assistance for bathing, hygiene, dressing upper body, walking, locomotion, and toilet transfer. She requires limited assistance for eating. She is independent for bed mobility. She is frequently incontinent of urine and occasionally incontinent of stool. She uses Pull-Ups for incontinence care. There was no pressure ulcer present. At issue is the medical necessity of personal care aide hours from 7 days a week, 10 hours a day to 7 days per week live-in. 

The requested health service of increasing personal care aide hours from 7 days a week, 10 hours a day to 7 days per week live-in is medically necessary for this patient.
The patient requires personal care assistance for all activities of daily living including ambulation, transfers, toileting, and incontinence care. She also has dementia which will complicate her care; she will require prompting and cueing to initiate personal care tasks. Her personal care needs are expected to be continuous and unscheduled throughout the day and occasionally at night time as well. Therefore, 24-hour live-in personal care is medically necessary and appropriate for the patient. Failure to provide for her personal care tasks could result in further injury, skin breakdown, and/or infection.