Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase in consumer directed personal assistance program (CDPAP) services to 12 hours/day, 7 days/week for a total of 84 hours/week
The insurer denied the increase in CDPAP services to 12 hours/day, 7 days/week for a total of 84 hours/week.
The health plan's determination is overturned.

The patient is a female with medical history notable for dementia, incontinence of bowel and bladder, and arthritis. The patient is approved for 8.5 hours/day, 5 days/week of consumer directed patient care assistance (PCA) and 8.5 hours/day, 2 days/week of PCA (total 59.5 hours/week). The patient and her care team requested an increase to 12 hours/day, 7 days/week of consumer directed personal assistance program (CDPAP, total 84 hours/week). This request was denied by the insurance plan, and this denial is the subject under review.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was found to have severely impaired cognition; she was alert and oriented to person only and had non-intelligible communication throughout the interview. She is not able to self-direct her care. For her functional status, she requires total dependence for meal preparation, housework, managing finances, stairs, and shopping. She requires maximal assistance for managing medications. For her activities of daily living (ADLs), she requires maximal assistance for nearly all, including bathing, hygiene, dressing upper/lower body, walking, locomotion, and toilet transfer. She requires limited assistance for toilet use and bed mobility. She is frequently incontinent of urine and occasionally incontinent of stool. She wears diapers and uses chux (disposable underpads) for incontinence care. She is unable to manage toilet transfer independently due to progressing dementia and functional mobility limitations. She requires weight bearing assistance for nearly all activities. Compared with a prior UAS, she demonstrated need for higher levels of assistance with toilet transfer and eating. A task tool associated with the most recent UAS recommended 49 hours/week to address her personal care needs, which was unchanged from the recommendation in the prior assessment.

The requested increase in CDPAP services to 12 hours/day, 7 days/week for a total of 84 hours/week is medically necessary for this patient.

The patient has advanced dementia. She is unable to care for herself or make her needs known. She requires human assistance for all of her ADLs and instrumental activities of daily living (IADLs). Despite worsening over the recent years, she has not received additional hours. The patient's family has been providing informal support and additional paid support, but they are no longer able to do so. The patient has incontinence and requires assistance with changing diapers and transfer to the bathroom as needed. In patients with incontinence and dementia, a task tool cannot reliably indicate the amount of PCA the patient needs. She will have numerous unscheduled and unpredictable needs that will cause the task tool to be inaccurate in its assessment. Failure to provide support for these personal needs could result in skin breakdown and/or infection.

PCA is not meant for safety monitoring and supervision. The patient cannot be left alone according to the assessment, but patient care aides should not be present solely for safety monitoring independent of providing support for ADLs. This patient has need for additional support for her functional needs, and additional hours would not be meant for monitoring alone.