Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple myeloma and chemotherapy induced
nerve disorder
Treatment: Consumer Directed Personal Assistance Program (CDPAP) for a Total of 168 Hours per Week (Split Shift)
The insurer denied the Consumer Directed Personal Assistance Program (CDPAP) for a Total of 168 Hours per Week (Split Shift)
The denial is overturned

This male patient has medical conditions including multiple myeloma and chemotherapy induced nerve disorder.  He is bed ridden.  He is appealing denial of increase consumer directed persona assistance program (CDPAP) for a total of 168 hours per week, split shift.  The plan approved 63 hours per week.  

Uniform Assessment System (UAS) evaluation completed shows the patient has independent cognition and total dependence with activities of daily living (ADLs).   He is bedridden and uses a Hoyer lift for transfer.  He is frequently incontinent of bowel.  

A statement from the patient's child notes the patient cannot walk and does not have use of his hands.  He needs assistance with activities of daily living (ADLs).  He had live-in informal support that is no longer available resulting in no assistance during nighttime.  A statement from the patient's child notes the patient has several chronic conditions, including a nerve disorder affecting his ability to use his extremities, chronic diarrhea and non healing bed sores.  The statement notes the patient is bedridden and needs rotation every two hours.  He has frequent urinary tract infections (UTIs) and multiple hospital admissions due to difficulty keeping catheter clean.

Yes, the proposed treatment is 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.  Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift.

This patient has chronic conditions resulting in him being bedridden.  He is appealing denial of increase consumer directed personal assistance program (CDPAP) for a total of 168 hours per week, split shift.  The plan approved 63 hours per week.  Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs).  He has a urinary catheter and has bowel incontinence.  Statements provided by the patient's child provide additional information of chronic diarrhea with skin breakdown and need for turning every two hours.  He also has recurrent urinary tract infections due to inability to clean himself that result in hospitalization.  This patient has significant physical impairments that result in him being fully dependent with activities of daily living and personal care.  In addition, the patient needs frequent turning/repositioning that requires continuous care.   He no longer has informal support to cover needs beyond the approved consumer directed personal assistance program 63 hours per week.  The approved consumer directed personal assistance program 63 hours per week is inadequate to meet the patient's needs for assistance with activities of daily living (ADLs) / instrumental activities of daily living (IADLs).  The proposed increase in consumer directed personal assistance program for a total of 168 hours per week, split shift, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.