Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Nursing Services (including Private Duty Nursing)

Diagnosis: Dementia
Treatment: Consumer Directed Personal Assistance Services
The insurer denied Consumer Directed Personal Assistance Services: 24 Hours per Day, 7 Days per Week (Split Shift). The health plan's determination is overturned. 

The patient is a female with past medical history of cerebrovascular accident (CVA), memory loss, constipation, coronary artery disease (CAD), hyperlipidemia, hypertension, osteoarthritis, urinary incontinence, stool incontinence, anxiety, and depression who had been assigned CDPAS (Consumer Directed Personal Assistance Services) 10 hours/day, 5 days/week and 5 hours/day, 2 days/week to total 60 hours/week. There was a request to increase the CDPAS services. The patient underwent assessment tool over the phone assessing her at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, and locomotion while maximal assistance with tasks of managing medication, phone use, bathing, dressing lower body, transfer toilet, and toilet use. The patient was assessed at extensive assistance with tasks of personal hygiene, dressing upper body, bed mobility, and eating. Notes from the assessment stated the patient was fed a mechanical soft diet, was wheeled by others for locomotion, had a fall with fractured finger, had a hospital bed, was having increase agitation and aggressive behavior. The assessment noted the patient had an informal helper who was able to continue caring activities.

Consumer Directed Personal Assistance Services: 24 Hours per Day, 7 Days per Week (Split Shift) is medically necessary for this patient. The patient needs 24-hour care based on her medical diagnoses and functional assessment. The patient's family and primary care physician (PCP) documented the patient's urinary and bowel incontinence with need for assistance with toilet use/incontinence cares. The patient also is not able to turn or reposition in her bed on her own and has had sore/wound on her ankles due to crossing her legs. The patient's toileting needs would not be able to be scheduled and the plan failed to document a plan of care that would take into account the patient's inability to toilet herself or provide herself with incontinence cares in the overnight hours. The patient's toileting needs, and incontinence care would not allow an overnight aide 5 hours of uninterrupted sleep. There is also documentation that the patient is bedbound and unable to turn/reposition in bed and therefore would need turning and repositioning at intervals where an overnight aide would not be able to have 5 hours of uninterrupted sleep. Split-shift CDPAS hours are not solely for safety and supervision but to assist the patient with safe completion of ADL tasks. Taking into account the clinical standards, all of the information provided regarding the patient, the attending physician's/provider's recommendation, and the applicable and generally accepted practice guidelines, CDPAS services, 24 hours/day, split-shift, are medically necessary for this patient. CDPAS/PCA services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.