Diagnosis: Dementia.
Treatment: Long-term custodial care.

The insurer is denied coverage for long-term custodial care.

The denial is overturned.

This female patient has a history of hypertension, dementia, unsteadiness, generalized epilepsy, nontraumatic subarachnoid hemorrhage, uterovaginal prolapse and cardiac pacemaker.

While the medical record indicates that during the examination, she was able to respond, one has to look at this individual globally in terms of her having Alzheimer's disease and periods of confusion and that she had a subdural hematoma. She has a pacemaker. It seems unreasonable to expect the family to render 24-hour safe care to this individual. The requested institutionalization is reasonable and appropriate.

While the indication was that the patient could feed herself, the medical record does in fact show that there are periods of mental confusion and that she has Alzheimer's disease. She has comorbid conditions of hypertension and a pacemaker, and recently had a subdural hematoma. It seems that this individual is at great risk for falling and sustaining another subdural hematoma. It is unreasonable to expect the family to have 24-hour care in this very fragile individual. As such the request for institutionalization is reasonable and appropriate.

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

The carrier's denial of coverage for the long-term custodial care is overturned. The medical necessity is substantiated.