Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Congestive heart failure, diabetes and osteoarthritis.
Treatment:  Consumer and self-directed personal assistance services 24 hours a day split shift (two 12 hour shifts per day), 7 days a week, a total of 168 hours a week.
The insurer denied coverage for consumer and self-directed personal assistance services 24 hours a day split shift (two 12 hour shifts per day), 7 days a week, a total of 168 hours a week.  
The denial is modified.
 
This is an elderly adult with chronic medical problems including congestive heart failure, diabetes and osteoarthritis who lives alone in a 2-bedroom apartment.  The insurer approved consumer and self-directed personal assistance services 56 hours per week and the request is for consumer and self-directed personal assistance services 24 hours a day, 7 days a week (split shift), totaling 168 hours per week.

The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as "Minimally impaired."  She is totally dependent to maximal assistance for much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She is also totally dependent for much of her functional mobility including locomotion, ambulation and toilet transfer/use.  Maximal assistance is needed for bed mobility as well as bathing and dressing.  Extensive assistance is needed for personal hygiene.  Limited assistance is needed for eating.  She is frequently incontinent of bladder and occasionally incontinent of bowel.  There have been no reported falls over the prior 90 days.  

The patient's medical condition and functional ability are not at a level or unpredictable as to require the requested consumer and self-directed personal assistance services 24 hours a day, 7 days a week (split shift), totaling 168 hours per week.  The night logs were also reviewed.  The care provided was toileting and bathing.  The patient has been provided with incontinence supplies, and bathing can be performed during the day shift.  

This physician would agree that the patient may benefit from monitoring for safety, particularly due to her decreased mobility.  However, consumer and self-directed personal assistance services for companion care or safety supervision without the direct provision of activities of daily living (ADL) task assistance is not a covered service.  Based on the enclosed documents reviewed including the medical reports and physical therapy notes, the patient health and safety are more appropriately provided and maintained at home by increasing consumer and self-directed personal assistance services to 12 hours/day, 7 days/week totaling 84 hours/week.  However, the requested consumer and self-directed personal assistance services 24 hours a day, 7 days a week (split shift), totaling 168 hours per week is not demonstrated as medically necessary. 

From a physical medicine and rehabilitation perspective, consumer and self-directed personal assistance services (CDPAS), 24 hours a day, 7 days a week (split shift), for a total of 168 hours a week is not medically necessary.  However, increasing consumer and self-directed personal assistance services to 12 hours/day, 7 days/week totaling 84 hours/week is medically necessary.    

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 consumer and self-directed personal assistance services 24 hours a day split shift (two 12 hour shifts per day), 7 days a week, a total of 168 hours a week services is not substantiated. 

However, Consumer and self-directed personal assistance services increased to 12 hours/day, 7 days/week totaling 84 hours/week is medically necessary.