Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease
Treatment: personal care services, 24 hours a day, 2 days a week (split shift)
The insurer denied coverage for personal care services, 24 hours a day, 2 days a week (split shift)
The denial is overturned.

This case involves an advanced elderly patient with Alzheimer's disease who was being assessed for increasing personal care services, 24 hours a day, 2 days a week (split shift) Saturday and Sunday. The records included assessments both prior and recent.  The initial assessment indicated that the patient required assistance with activities of daily living (ADLs), and instrumental activities of daily living (IADLs), shopping, meal preparation, house work, and to stay free from falls. The patient lived alone in an apartment on the second floor. He had impairments with cognition to include poor or unsafe decision-making. The patient always required cues/supervision and had a decline in mental health in terms of memory problems. The patient was forgetful with episodes of confusion and wandering was an issue. At the time of the assessment, the patient was receiving 40 hours a week of consumer directed and personal care services during the weekdays. He was having daily episodes of urinary incontinence and bowel incontinence and required adult pull-ups. He had moderate fatigue due to diminished energy and mild levels of pain occurring intermittently. The patient's last recorded fall required hospitalization for 12 days. The patient was expected to need continued services for a period of 120 days or more from the assessment date.  

When he was reassessed, the patient's conditions were unchanged. He continued to require extensive to total dependence with meal preparation, managing medications, phone use, navigating stairs, shopping, and transportation as well as most activities of daily living.  He had no reported falls in the last 90 days and continued to have diminished energy.  He reported moderate levels of pain occurring intermittently and had a strong and supportive family. An appeal was submitted regarding the denial of coverage for an increase to a total of 48 hours (Saturday and Sunday) a week of personal care services.  The appeal stated that the patient lives alone in the community with a diagnosis of Alzheimer's disease, depression, diabetes mellitus, orthostatic hypotension, iron deficiency anemia, and bowel/bladder incontinence. The physician argued that the patient already required extensive to total assistance with nearly all activities of daily living. Additionally, given his incontinence, he requires frequent diaper changes to prevent skin breakdown and hospitalization. This review pertains to personal care services, 24 hours a day, 2 days a week (split shift).

Personal assistant services allow patients (who are able) to remain in the comfort of their home rather than being forced to live in a skilled nursing facility or assisted living. The documentation provided for the review indicated that the patient in question is of advanced age, lives alone in the community with a diagnosis of Alzheimer's disease, depression, diabetes mellitus, orthostatic hypotension, iron deficiency anemia, and bowel/bladder incontinence. He was previously approved for 40 hours a week of consumer and self-directed personal assistant services. He was also receiving 16 hours per week (8 hours a day, 2 days a week), Saturday and Sunday in Personal Care Services.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care services, 24 hours a day, 2 days a week (split shift) services is substantiated.