Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: consumer directed personal assistance program (CDPAS); 7 days per week, 24 hours a day (split-shift).
The insurer denied consumer directed personal assistance program (CDPAS); 7 days per week, 24 hours a day (split-shift).
The determination is overturned.

The patient has a past medical history of diabetes mellitus type 2, bladder incontinence, dementia, chronic obstructive pulmonary disease (COPD), lung cancer, hyperlipidemia, hypertension, osteoporosis, anemia, chronic kidney disease, bladder cancer, and permanent pacemaker who had been assigned 48 hours of Consumer Directed Personal Assistance Program (CDPAP) services based on an assessment assessing the patient at total assistance with the tasks of meal preparation and ordinary housework while maximum assistance with tasks of managing finances, managing medication, and shopping. With the tasks of stairs, transportation, bathing, personal hygiene, dressing lower body, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of phone use, dressing upper body, walking, locomotion, and bed mobility. The patient was assessed at independent with the task of eating and notes from the assessment stated the patient lived with her daughter.
The patient had an emergency room visit following a fall in the middle of the night when she was trying to go to the bathroom with an x-ray performed of her chest during evaluation of her fall showing a new lung mass. The patient was subsequently referred to oncology and underwent a positron emission tomography (PET) scan. The PET scan did not show metastases but did confirm a hypermetabolic mass in the left upper lobe and the patient was referred to radiation oncology and was seen with no plan for biopsy or treatment. The patient had a hospitalization with mental status changes and extensive evaluation with imaging and lab work. The patient was noted to have Mobitz 2 and did have permanent pacemaker placed. It was felt delirium was likely related to worsening dementia with subsequent transfer to rehabilitation. The patient was discharged to home.
The patient's primary care physician (PCP) provided a letter of medical necessity for 24-hour home care stating the patient had recently been seen in the office and it was their medical opinion that the patient required 24-hour care to meet the patient's medical, psychological, and social welfare needs. The provider noted the patient required round-the-clock supervision, was at high risk for falls, and required continuous monitoring and assistance with all activities of daily living as well as independent activities of daily living. The patient's PCP provided another letter of medical necessity for 24-hour home care also recommending to reference recently submitted Department of Health (DOH) 4359 for details.
There was a request to increase CDPAP services and the patient underwent a telephonic assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, phone use, stairs, transportation, bathing, dressing lower body, transfer toilet, and toilet use. With the tasks of personal hygiene, dressing upper body, walking, and locomotion, the patient was assessed at extensive assistance while limited assistance with tasks of bed mobility and eating.
The insurer sent an initial adverse determination denial notice denying the request to increase services stating the patient's family was supportive and were available to help as needed and the patient had informal supports who were available to help her daily and during the week. In addition the denial stated the patient had equipment in her home for assistance and safety. The denial also stated the medical notes did not show needs that would require a care plan of split shift 12 x 2 hours, 7 days a week. Lastly, the denial recommended using the current hours throughout the week to cover her care needs.
The patient had a follow-up visit with her PCP with the office visit note stating the daughter reported the patient was getting worse with physical movement and had fallen twice, had difficulty ambulating and needed assistance, was confined to a room without a bathroom and was unable to use a regular toilet. In addition, the office note stated the patient was not able to reach the bathroom in a reasonable time. The insurer sent a final adverse determination denial notice partially denying the request to increase CDPAP services by increasing the services to 56 hours/week. The denial also stated personal care services were to be provided in the amount and quantity required to meet care plan needs and safety monitoring should not be authorized in the absence of an activities of daily living (ADL) need. The patient's healthcare advocate requested an external appeal of the denial decision stating the patient had experienced a decline in her cognitive functioning and mobility over the last year, was at high risk for falls, was recently diagnosed with lung cancer, had increased incontinence of bowel and urine, had increased difficulty breathing due to the onset of lung cancer, required assistance with toileting, repositioning in bed and with her nebulizer throughout the night. In addition, the advocate's letter stated the patient had 2 daughters who were her personal care aides but one of them worked outside the home and was only available to care for the patient 8 hours/week; however, if more hours were authorized for the patient, she would be willing to work more hours as a personal care aide for the patient. The advocate letter also stated the patient was prescribed albuterol to be administered every 4 hours but needed cueing and supervision to utilize the nebulizer.
At issue is the medical necessity of consumer directed personal assistance program (CDPAS); 7 days per week, 24 hours a day (split-shift).
The services are medically necessary. There is documentation of worsening cognitive and physical functioning of the patient in the last 12 months as documented in emergency room notes, hospital admission notes, discharge summary notes, rehabilitation notes, PCP notes, and healthcare advocate notes. The plan's own assessments have documented an increase in assistance with multiple ADLs and Instrumental activities of daily living (IADL). The patient has 24-hour care needs and a task based assessment should not have been utilized. The patient requires at least limited assistance with all ADLs/IADLs. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The patient requires assistance with incontinence cares and requires assistance with bed mobility in the overnight hours. In addition, the patient has been prescribed nebulized medication every 4 hours and requires assistance and cueing and therefore a CDPAP service aide would not be able to obtain at least 5 hours of uninterrupted sleep and therefore split shift services are medically necessary. The patient's primary care physician has documented the medical necessity of increased CDPAP services at 24 hours/day. The patient's care needs cannot be met solely with medical supplies and adaptive equipment. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs.
Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 24 hours/day, split-shift, 7 days/week are medically necessary for this patient. Personal care 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.