Diagnosis: Dementia
Treatment: Increase Consumer Directed Personal Assistance Services to 100 Hours A Week
The insurer denied the Increase Consumer Directed Personal Assistance Services to 100 Hours A Week
The denial is overturned

The patient is a female with cognitive impairment. The request is for increase Consumer Directed Personal Assistance Services to 100 Hours a Week for personal assistance service to ensure the patient eats and bathes, as well as ensuring a safe environment. The request is also for toileting and medication administration. The patient refuses to shower, and cannot make food. She has trouble remembering to keep her life alert device nearby.

The request for increasing Consumer Directed Personal Assistance Services to 100 Hours was because, per the family-submitted note, the patient has Alzheimer and sundowning. The family are requesting 100 hours because the patient is fall risk at night.

Yes , the requested Consumer Directed Personal Assistance Services to 100 Hours A Week is medically necessary.
The patient does have severe dementia. She needs assistance with food and activities of daily living. The patient does have multiple awakenings at night. She does not know how to use life alert. She has history of falls at night. She does not have self-awareness.

Therefore, given the above, the requested Consumer Directed Personal Assistance Services to 100 Hours/week is medically necessary.

No, The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The requested Consumer Directed Personal Assistance Services to 100 Hours/week is appropriate.

The patient needs assistance preparing food and showering, and monitoring at night. The patient has severe dementia. She needs assistance with food and activities of daily living. The patient has multiple awakenings at night. She does not know how to use life alert. She has history of falls at night. She does not have self-awareness.