Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer Directed Personal Assistance Program (CDPAP) 9 hours (hrs) per day - 7 days per week for a total of 63 hrs per week
The insurer denied the Consumer Directed Personal Assistance Program (CDPAP) 9 hours (hrs) per day - 7 days per week for a total of 63 hrs per week.
The health plan's determination is overturned.

The patient is a female with a medical history notable for dementia, gait instability, and incontinence of bowel and bladder. The patient is approved for 7 hours per day, 7 days per week (49 hours per week) for the Consumer Directed Personal Assistance Program (CDPAP). The patient and her care team requested an increase to 9 hours per day, 7 days per week (63 hours per week) and this request was denied by the health plan.
A letter of support for this appeal was provided by the patient's legal team. The letter states that the patient lives with her daughter, who normally provides informal support to her mother during times that her personal care aide is not available. However, the patient's daughter is now required to go into the office for additional hours. This will leave the patient without home health coverage (or informal family support) for her personal care needs, including medication assistance and toileting. The requested additional hours would help to cover this gap in her personal care needs.

The patient's daughter provided a letter of support for this appeal. The letter states that she is requesting the additional hours to cover for the hours that she will no longer be able to be present for her mother. She states that the patient requires assistance in all activities including toileting and the patient cannot be left alone during this time.

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was completed in-person. The patient was alert and oriented to person and place only. Her recall was 0 out of 3 at five minutes. She cannot perform a multi-step command. She is unable to verbalize her needs due to dementia. With regards to her functional status, she requires total dependence for housework and finances. She requires maximal assistance for meal preparation, medications, phone use, and shopping. For her activities of daily living (ADL), she requires maximal assistance for bathing and dressing lower body. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, toilet use, and bed mobility. She is frequently incontinent of stool and urine. She was observed walking with a walker and has an unsteady gait, and requires some weight bearing assistance. She requires assistance for toileting and changing diapers.

The requested health service/treatment of Consumer Directed Personal Assistance Program (CDPAP) 9 hrs per day - 7 days per week for a total of 63 hrs per week is medically necessary for this patient. The patient has dementia and is incontinent of stool and urine. She is not able to care for her own toileting needs. She can be expected to have continuous and unscheduled personal care needs throughout the day. She needs assistance with these activities, and additional hours would not be meant solely for the purposes of safety monitoring and supervision. The patient's daughter has been filling in for this role by providing informal support. Because she is no longer able to do so for a 2 hour window each day, it is medically necessary for the health plan to provide for the additional hours as requested.
The health plan's determination of medical necessity is overturned in whole.