Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dementia
Treatment: consumer directed personal assistance program (CDPAP): 12 hours per day-7 days per week for a total of 84 hours per week 
The insurer denied consumer directed personal assistance program (CDPAP): 12 hours per day-7 days per week for a total of 84 hours per week. 
The determination is overturned in part.

This is a patient with a medical history notable for dementia, end stage renal failure, obesity, diabetes, lymphoma, and severe osteoarthritis of the spine. The patient was approved for 6 hours per day, 7 days per week (42 hours per week) of Consumer Directed Personal Assistance Program (CDPAP) services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week). This request was denied by the insurance company and this denial is the subject under review.

The patient's most recent office visit note from her treating physician was provided for review. The visit took place after a recent admission to the hospital for renal failure, at which point she was started on hemodialysis. The note describes that she has had a decline in function since the hospitalization and as a result has difficulty with all activities of daily living. The patient's family reports that dementia symptoms have significantly worsened after the hospitalization as well. The treating physician recommended increasing home health aide hours to compensate for her worsening condition.
A Uniform Assessment System (UAS) was completed and was available for review. The patient's cognition was found to be moderately impaired with consistently poor and unsafe decision making. She was alert and oriented times two, had 0/3 recall at 5 minutes, and was unable to recall what she had for breakfast that morning. From a functional standpoint, she requires total dependence for meal preparation, housework, managing finances, transportation, and shopping. She requires maximal assistance for managing medications, phone use, and walking. For her activities of daily living (ADLs), she requires maximal assistance for bathing, dressing lower body, walking, and toilet transfer. She requires total dependence for locomotion. She requires extensive assistance for hygiene, dressing upper body, toilet use, and bed mobility. She is only able to ambulate with a walker with significant caregiver support. She is frequently incontinent of urine (daily), and occasionally incontinent of stool. She uses pull-ups for incontinence care. When compared with the prior UAS , she has shown a decline in the following areas: cognition, dressing upper and lower body, hygiene, toilet transfer, bathing, walking, locomotion, and bed mobility.

A task tool associated with the most recent UAS recommended 7.5 hours per day (52.5 hours per week) to meet her personal care needs. This was an increase from the prior assessment, which recommended 6 hours per day. At issue is the medical necessity of consumer directed personal assistance program (CDPAP): 12 hours per day-7 days per week for a total of 84 hours per week medically necessary for this patient.

The requested health service/treatment of consumer directed personal assistance program (CDPAP): 12 hours per day-7 days per week for a total of 84 hours per week is medically necessary in part for this patient.

The patient has had a clear medical and functional decline since her recent hospitalization. The UAS report demonstrates medical necessity for increase in personal care service hours as indicated by a decline in most domains. She has had worsening of her dementia. This will compound all aspects of her care, as she is less able to make her needs known and personal care activities may take more time than they did previously. The UAS recommended an increase to 7.5 hours per day. This should be looked at as a minimum needed to address her needs, and she is currently only approved for 6 hours per day. Because she has consumer directed personal care needs, the patient and her family can use hours strategically to optimize her care. 9 hours per day would be an appropriate allotment of personal care hours for a person with this level of required assistance.

CDPAP 9 hours per day, 7 days per week (63 hours per week) is medically necessary.