Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Diabetes, hypertension, sleep disorder, anemia, depression, and amnesia. 
Treatment:  Increase Consumer Directed Personal Assistance Program (CDPAP) Services to 12 hours/day - 7 days/week, Split Shift for a Total of 168 Hours per Week.

The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP) Services to 12 hours/day - 7 days/week, Split Shift for a Total of 168 Hours per Week.  The denial is upheld.

The patient is an elderly female with multiple medical comorbidities including diabetes, hypertension, sleep disorder, anemia, depression, and amnesia who was initially approved for eight hours per day, seven days per week (56 hours per week) of Consumer Directed Personal Assistance Program. The request is for an increase Consumer Directed Personal Assistance Program (CDPAP) Services to  12 hours/day - 7 days/week, Split Shift for a Total of 168 Hours per Week. A note from the patient's physician notes that the patient has vertigo and poor vision in addition to her other medical conditions and is at increased risk of falls. The provider notes that she needs assistance with dressing, showering, medications, and food intake. Uniform Assessment System (UAS) evaluation completed recently reflects that the patient is totally dependent for meal preparation, housework, and shopping. She requires maximal assistance for managing medications, bathing, personal hygiene, dressing, walking, toilet transfer and use. She requires extensive assistance for eating.

The plan denied the request for split shift (168 hours per week) as not medically necessary noting that the hours would remain the same at eight hours per day, seven days per week (56 hours per week). In a final adverse determination letter the plan 
upheld the initial denial, noting that the current hours safely meet the patient's personal care needs and that granting additional hours are not provided when tasks are not being performed.

On appeal, the patient's representative notes that the patient cannot perform any tasks by herself and that she has worsening amnesia. The appeal information notes that the patient is not sleeping well at night, gets up at night and falls. 

The proposed treatment (i.e., Increase Consumer Directed Personal Assistance Program (CDPAP) Services to 12 hours/day - 7 days/week, Split Shift for a Total of 168 Hours per Week) is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. The request is for an increase in Consumer Directed Personal Assistance Program (CDPAP) Services to 12 hours/day - 7 days/week, Split Shift for a Total of 168 Hours per Week. The submitted documentation does not reflect which activities of daily living cannot be completed with the currently approved 56 hours per week. Time for housework, meal preparation, personal hygiene, toileting, and dressing, have already been accounted for in the hours approved by the plan. The Consumer Directed Personal Assistance Program allows the patient's designated representative the flexibility to allocate the approved hours in a way that best meets the patient's needs. The patient is also noted to have equipment at home to assist with her activities of daily living and keep her safe, including a toilet seat, shower chair, shower grab bar, walker, and supplies for incontinence. Moreover, there is no evidence of frequent night-time personal care needs (e.g., frequent turning, frequent toileting needs). The appeal information notes that the patient has amnesia and gets up at night; however, personal care services are not covered for supervision and safety concerns, per New York State Guidelines. Based on the available information, eight hours per day, seven days per week (56 hours per week) of Consumer Directed Personal Assistance Program are sufficient to meet the patient's needs. Thus, the Increase Consumer Directed Personal Assistance Program (CDPAP) Services to 12 hours/day - 7 days/week, Split Shift for a Total of 168 Hours per week is not medically necessary.