Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Benign prostatic hyperplasia, diabetes mellitus type 2, dysphagia and aphasia

Treatment: Consumer directed personal assistant services (CDPAS) - 24 hours a day, split shift (two 12-hour shifts), 7 days a week totaling 168 hours.

The insurer denied coverage for consumer directed personal assistant services (CDPAS) - 24 hours a day, split shift (two 12-hour shifts), 7 days a week totaling 168 hours.
The denial is overturned.

This case involves a male with a history of multiple medical conditions to include benign prostatic hyperplasia, diabetes mellitus type 2, dysphagia, aphasia due to a traumatic brain injury, a history of seizures, unsteady gait, a PEG (percutaneous endoscopic gastrostomy) tube, dementia, and falls. He was being recommended for personal assistance services 24 hours a day with a split shift of two 12-hour shifts, 7 days a week totaling 168 hours.  An assessment noted that the patient was oriented to person only and required assistance with cooking, cleaning, laundry, shopping, bathing, dressing, toileting, eating, walking, and personal hygiene. Records stated that the patient was previously approved for 76 hours of personal assistance per week with claims that the patient required help managing medical conditions or behavior, which is outside the scope of practice of the personal aide. The patient was advised to always use a mobility device for safety with claims that an aide could not prevent the patient from falls or injuries. The report also claimed that the patient should utilize the incontinence products to help with toileting needs and wear easily removable clothing making it easier for the patient to use the toilet and a portable extendable toileting aid to help with toileting hygiene. This review pertains to the denial of coverage for consumer directed personal assistant services (CDPAS) - 24 hours a day, split shift (two 12-hour shifts), 7 days a week totaling 168 hours. 

The healthcare plan did not act reasonably and was so medical judgment and in the best interest of the patient.

Consumer directed personal assistance service (CDPAS) - 24 hours a day, split shift (two 12-hour shifts), 7 days a week totaling 168 hours is considered medically necessary for this patient.

Literature notes that everyday household activities, such as taking a bath, walking to a street side mailbox, or even adjusting a thermostat, may create a variety of problems for older individuals who experience age-related loss of musculoskeletal and sensory functioning. These individuals often report that, with functional loss, routine activities become more difficult, more time-consuming, and more hazardous. His spouse is only able to provide limited services given her advanced age and physical capabilities, and for the safety of the patient, he requires around-the-clock care to prevent falls and further injury. His wife, a retired nurse, has been able to oversee his care and provide skilled tasks. However, due to her own age, she is unable to provide personal care services to him during the 13 hours a day which he receives no aide services. It was therefore determined that the previously approved 76 hours of personal assistance is inadequate for this individual. After a thorough review of the provided information, it was determined that the prior determination should be overturned given that the consumer directed personal assistance service (CDPAS) - 24 hours a day, split shift (two 12-hour shifts), 7 days a week totaling 168 hours is medically necessary.

The insurer's denial of coverage for consumer directed personal assistance service (CDPAS) - 24 hours a day, split shift (two 12-hour shifts), 7 days a week totaling 168 hours is overturned. Medical Necessity is substantiated.