Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Stroke, hypertension and diabetes

Treatment: Increase in consumer directed personal care assistance services (CDPAS) from 63 hours per week to 24 hours per day (split shift)

The insurer denied coverage for an increase in consumer directed personal care assistance services (CDPAS) from 63 hours per week to 24 hours per day (split shift)

The denial is modified.
 

This is an elderly female with chronic medical problems including stroke, hypertension and diabetes. She lives alone in a 1 bedroom apartment. The insurer approved consumer directed personal assistance services (CDPAS) 63 hours/week. The request is for CDPAS 24 hours a day (split shift); leading to an external review. 

The Uniform Assessment System (UAS) was reviewed. The patient' cognition is described as moderately impaired. She is reportedly total dependent for completing much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is also reportedly totally dependent for toilet use and locomotion. Maximal assistance is reportedly needed for bathing, lower body dressing, and toilet transfer. Extensive assistance is reportedly needed for personal hygiene, upper body dressing and bed mobility. She is non-ambulatory. The patient reportedly requires supervision when eating. She is incontinent of bladder and bowel. 

The patient's activities of daily living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. There have been no reported falls over the prior 90 days. The patient's cognition is much the same when compared to the UAS report several months ago. However, her functional ability has declined. The letter from the patient's treating physician, describes her clinical condition and reported need for additional care assistance. The doctor does not include the associated treatment notes to support her claim of the patient's reported functional incapacity. The Night Time (care) Logs were also reviewed. The patient's condition and functional deficits are not at a level or unpredictable as to require the requested increase in CDPAS 24 hours/day (split shift). This physician would agree that the patient may benefit from additional monitoring; particularly due to her reported cognitive decline and falls risk. However, safety monitoring under CDPAS does not include monitoring an individual (e.g., with dementia, falls risk, general weakness) when no other Level I or Level II personal care services task is being provided. Based on the clinical records, and given her documented functional decline the patient' health and safety are more appropriately provided and maintained at home by increasing CDPAS 12 hours/day, 7 days/week; total 84 hours/week. 

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in consumer directed personal care assistance services (CDPAS) from 63 hours per week to 24 hours per day (split shift) services is not substantiated. However, increasing CDPAS to 12 hours/day, 7 days/week; 84 hours/week is medically necessary.