Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus, chronic kidney disease, generalized osteoarthritis
Treatment: Increase Home/Personal Care Consumer Directed 
Assistance (CDPA) to 24 Hours per Day (Split Shift)
The insurer denied: Increase Home/Personal Care Consumer Directed Assistance (CDPA) to 24 Hours per Day (Split Shift)
The denial is overturned.

The patient is an elderly male with a history of general debility due to dementia. The request was for Consumer Directed Assistance (CDPA) to be increased from 24 hours per day, live-in, 7 days a week, based on Uniform Assessment System (UAS) evaluation of 9 months ago to 24 hours per day split-shift, 7 days a week, based on Uniform Assessment System (UAS) evaluation of 3 months ago. The health plan denied the request because neither the patient's activities of daily living (ADL) status nor his overall self-sufficiency has changed significantly while his medical diagnoses are only minimally changed. The additional hours requested are because of the patient's chronic medical conditions with a rapid decline in physical, mental, and cognitive status, and to help with his activities of daily living (ADLs) as he has cognitive decline and requires extensive assistance with most of his activities of daily living. A review of the records showed that the patient has multiple chronic medical conditions including dementia, anxiety, insomnia, sun-downing syndrome, chronic infarction of the left occipital lobe, seizures, diabetes mellitus, chronic kidney disease, old myocardial infarction, coronary artery disease (CAD), congestive heart failure (CHF), 
hyperlipidemia, hypertension, anemia, generalized osteoarthritis, and inguinal hernia. Uniform Assessment System - New York (UAS-NY) evaluation of 3 months ago showed that the patient is moderately cognitively impaired with decisions consistently poor or unsafe with cues needed at all times, required supervision for eating, required limited assistance with managing medications, phone use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, bed mobility, eating, extensive assistance with personal hygiene, upper body dressing, walking, locomotion, toilet use/transfer, maximal assistance for managing medications, phone use, stairs, transportation, bathing, lower body dressing, and totally dependent for meal preparation, housework, managing finances, and shopping. The patient lives with his daughter and son-in-law on the first floor of a two-floor house in a 2-bedroom apartment.

The requested increase for Personal Care Consumer Directed Assistance (CDPA) to be increased from 24 hours per day, live-in, 7 days a week to 24 hours per day split-shift, 7 days a week is medically necessary.

The requested service is medically necessary because the patient is moderately cognitively impaired with decisions consistently poor or unsafe with cues needed at all times, required supervision for eating, required limited assistance with managing medications, phone use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, bed mobility, eating, extensive assistance with personal hygiene, upper body dressing, walking, locomotion, toilet use/transfer, maximal assistance for managing medications, phone use, stairs, transportation, bathing, lower body dressing, and totally dependent for meal preparation, housework, managing finances, and shopping. The reason for denial by the health plan as stated in the clinical information above, does not align with the patient's disability features as stated in the Uniform Assessment System evaluation of 3 months ago as stated above.
Therefore the 24 hours per day split-shift, 7 days a week requested should be approved.