Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's

Treatment: consumer directed personal assistance services (CDPAS) 24 hours of continuous care with split shift

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 24 hours of continuous care with split shift

The denial is overturned

This case involves an elderly patient who lives with their daughter and grandson in a 2 story home, and has their daughter and granddaughter as their Consumer Directed Personal Assistance Services (CDPAS) aides. The patient is noted to have a diagnosis of altered mental status, Alzheimer's disease, hypokalemia, hypertension, vascular dementia, insomnia, anxiety disorder, chronic kidney disease, aortic aneurysm, migraines, tremor, unsteady gait, high fall risk, gastroesophageal reflux disease, lightheadedness, hyperlipidemia, degenerative joint disease, coronary artery disease, thoracic aneurysm, unspecified hearing loss, anemia, sciatica, back pain, and incontinence. Current medications include alprazolam, Belsomra, amlodipine, biotin, citalopram, clopidogrel, eplerenone, Fioricet, fluticasone propionate nasal spray, loratadine, losartan potassium, mirtazapine, montelukast, Olmesartan, potassium chloride, rosuvastatin calcium, Tylenol, and vitamin D3. 

According to the community health assessment, the patient is alert and oriented x 1 to self, has severe hearing difficulty, moderate vision difficulty, has demonstrated verbal abuse daily in the last 3 days, and has wandered daily in the last 3 days. It was documented that the patient's self-sufficiency has deteriorated significantly in the last 90 days. A provider request form indicated that the patient requires an increase in home care hours due to the worsening of their health conditions. The treating physician stated that the patient requires total assistance with all activities of daily living (ADLs), and is at a high risk for falls. According to the Personal Care Tasking Tool, 56 hours per week of formal support are needed to meet the patient's needs. It was documented that the patient requires total dependence or maximal assistance for all activities. A determination letter indicated the request for consumer directed personal assistance services (CDPAS) 24 hours of continuous care with split shift was partially approved for consumer directed personal assistance services (CDPAS) 56 hours per week at 8 hours per day, 7 days per week, an increase from the initially approved 49 hours per week. The requested consumer directed personal assistance services 24-hour continuous care was partially denied, as according to the insurer, records do not provide evidence that the patient requires assistance during overnight hours. It was stated that 24-hour continuous care is only approved when a patient requires round-the-clock assistance with activities of daily living, and additional service hours should not be increased for supervision purposes alone. It was also stated that the patient was noted to be able to sleep while taking prescribed medications, receives both formal and informal support from family, and is never left alone. It was recommended that the patient's aide work a split shift by spreading the care hours throughout the day for appropriate utilization of services. 

Based on the above, the insurer's denial must be reversed. 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 consumer directed personal assistance services (CDPAS) 24 hours of continuous care with split shift services is substantiated.