Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours/day, 7 days/week, for a total of 84 hours/week.
The insurer denied the request for CDPAP: 12 hours/day, 7 days/week, for a total of 84 hours/week.
The health plan's determination is overturned.

The patient is a female with a medical history notable for Alzheimer's disease, gait abnormality, recurrent falls, osteoarthritis, type 2 diabetes, and hearing loss. The patient is approved for 6.5 hours/day, 7 days/week (45.5 hours/week) of consumer directed personal assistance program (CDPAP). The patient and her care team requested an increase to 12 hours/day, 7 days/week (84 hours/week) and this request was denied by the health plan. This denial is the subject under review.

The patient's primary care physician provided a letter of support for this appeal. The letter states that the patient has been progressively declining from a cognitive and functional standpoint. She has unsteady gait with multiple falls and history of a pelvic fracture. She has been getting more forgetful, confused, and uncooperative. The physician states that she requires additional home care hours to meet her needs.

The patient's daughter provided a letter of support for this appeal. The letter states that the patient has become significantly worse from a cognitive and health standpoint since the last assessment. She suffered another fall with a rehabilitation stay and since returning home has had worsening in nearly all aspects of function. She is incontinent and requires frequent assistance with changing and cleaning. She is in "dire need of assistance in everyday care and ambulation." The letter outlines all of the aspects of the most recent assessment and adverse determination which she believes are false. She states that as of now, the current accurate depictions for need for the patient are as follows: she is not able to direct her own care, she cannot ambulate independently with a walker, she cannot perform dressing, transfers, hygiene or toileting without assistance, she uses 4 to 5 diapers per day, among others. Additionally, the letter states that the patient's diapers are changed by her daughter or niece when able, but when they are not around and a caregiver is not available, the patient is left alone in a soiled diaper.

The most recent Uniform Assessment System (UAS) was conducted via teleconference. The patient's cognition was noted to be moderately impaired; she was alert and oriented to person and place only and requires supervision at all times for unsafe decisions. Her cognition is noted to vary throughout the day. Her recall was 0 out of 3 at five minutes and she is unable to perform procedural tasks. She cannot ask for help in an emergency. For her instrumental activities of daily living (IADLs), she requires total dependence for housework, finances, and shopping. She requires maximal assistance for meal preparation, medications, stairs, and transportation. For her activities of daily living (ADLs), she requires maximal assistance for bathing and extensive assistance for essentially all others. 

The patient has dementia and cannot direct her own care. She requires hands on assistance for all ADLs including transfers and toileting. She is incontinent of urine and requires frequent diaper changes. Her prior falls when attempting personal care tasks without a caregiver are evidence of unmet personal care needs. Her task tool is likely underrepresenting her true level of need; given her current functional status, she will be expected to have personal care needs that are continuous and unscheduled throughout the day. Therefore, the requested increase in CDPAP services is medically necessary and appropriate for the patient.

The health plan's determination of medical necessity is overturned in whole.