Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia 
Treatment: Personal Care Assistance Services of 48 hours per week 

The insurer denied the personal care assistance services of 48 hours per week. The denial was reversed. 

This is a female patient with a past medical history of a cerebral vascular accident with left hemiplegia, hypertension, post-stroke vascular dementia, significant cognitive impairment, schizophrenia and major depressive disorder. The patient had significant cognitive impairment and psychiatric symptoms which impair her functioning. There had been a reported recent fall when the patient did not have sufficient assistance due to the decrease in aide hours. It was noted that the patient lives with her son, however, due to his own medical conditions he is not readily available to care for his mother. The patient has multiple medical conditions involving her physical and mental health, which has resulted in substantial functional impairment with all daily activities. It is noted that the patient needs assistance with transfers. She has very slow, unsteady gait and uses a cane and needs caregiver assistance with walking due to loss of balance. She requires weight-bearing assistance with bathing, hygiene, toilet use, dressing. She has significant cognitive impairment including unsafe decision making, oriented x 1, memory impairment (short term), difficulty with attention, and some difficulty with verbal communication skills. A request was made for personal care assistance services of 48 hours per week. 

The patient has been followed by this psychiatric clinic for many years. The patient has diagnosis of schizophrenia, major depressive disorder and post-stroke vascular dementia with significant cognitive impairment. Her psychiatric symptoms have been active. The patient requires a home health aide 10 hours per day due to significant cognitive impairment and psychiatric symptoms which impair her functioning. 

The patient is dependent on a caregiver for all IADLs (total dependence or maximal assistance). For ADLs, the patient needs assistance (maximal, extensive or limited) for all except eating (supervision). It is noted that the patient needs assistance with transfers (rising from a seat). She has very slow, unsteady gait, uses a cane and needs caregiver assistance with walking due to loss of balance. She needs weight-bearing assistance with bathing, hygiene, toilet use, dressing. It is noted that she has difficulty bending which suggests possible arthritis of the spine. It is likely a combination of old neurologic deficits and some effects of arthritis cause her limited mobility. 

The patient has a long history of mental health disorders, including schizophrenia and depression. She also has vascular dementia as a result of her stroke. Aspects of all these conditions have a significant effect on the patient's functional capacity. The psychiatrist noted in a letter that the patient has active symptoms (nervousness, low mood, poor sleep). 

The patient is also high risk for falls. Her risk factors include: unsteady gait, arthritis, impaired balance, incontinence, dementia, advanced age, use of medications associated with fall risk (antihypertensive drugs, antidepressant). Falls in the elderly are associated with increased risk of serious injury (e.g. fractures, head trauma), increased morbidity and increased risk of death. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for the Personal Care Assistance Services of 48 hours per week is substantiated. The insurer's denial is reversed.