Diagnosis: Alzheimer's disease, dementia and osteoarthritis.
Treatment: Personal Care Services of 24 hours per day, 7 days per week (live-in).
The insurer denied coverage for Personal Care Services of 24 hours per day, 7 days per week (live-in).
The denial is overturned.

This is a female patient with a past medical history of heart failure, osteoarthritis, hyperlipidemia, rheumatoid arthritis, insomnia, unspecified pain, unspecified convulsions, Alzheimer's disease, dementia and wandering. The patient lives alone on the 19th floor of a 2- bedroom apartment. It has an elevator and has wheelchair accessibility. Her children and grandson are supportive in her care.

The patient's needs are: total dependence for meal preparation, ordinary housework, managing finances, shopping and transportation; maximal assistance for phone use;
extensive Assistance for managing medications, stairs, bathing, personal hygiene, dressing her upper and lower body and toilet use; limited assistance for walking, toilet transfer, bed mobility and eating (uses adult diapers). An increase of personal care services of 24 hours per day, 7 days per week (live-in) is being requested.

The health care plan did not act reasonably, with sound medical judgment and in the best interest of the patient. The reviewer does not agree with the plan's assessment of the patient's nighttime needs.

The patient has frequent urinary and occasional bowel incontinence. She has pull-ups, but is unable to change them or get herself out of bed to the bathroom (physical and cognitive limitations). She is already showing signs of the start of a pressure sore (heel). If it is starting in the heel, there would be concern about it happening in the sacral or other areas. Uniform Assessment System (UAS) documentation notes that the patient was instructed in proper diaper use, but given her cognitive and physical limitations she should not be expected to take care of herself at night. Lying in wet pull-ups for many hours would not be desirable, and she would need to be positioned after being cleaned. The provision of safety and supervision services in this case would be part of the larger services needed at night. The patient's request is approved.

The insurer's denial of coverage for the requested Personal Care Services of 24 hours per day, 7 days per week (live-in) is overturned. Medical necessity is substantiated.