Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Increase in Consumer Directed Personal Assistance Services (CDPAS) from 24 hours per day (Live-In) to 24 hours per day (Split-Shift)
The insurer denied an increase in Consumer Directed Personal Assistance Services (CDPAS) from 24 hours per day (Live-In) to 24 hours per day (Split-Shift).
The determination is overturned. 

This is a female patient with a history of stage four (IV) ovarian cancer, irritable bowel syndrome, hyperlipidemia, hypertension, arthritis, dementia, hypothyroidism, osteoarthritis, and osteoporosis. The patient was previously approved for Consumer Directed Personal Assistance Services (CDPAS) 24 hours per day (Live-in). The patient and her care team requested an increase in CDPAS to 24 hours per day (Split-shift).
A Uniform Assessment System (UAS) was completed. The patient was assessed at total dependence for meal preparation, ordinary housework, shopping, transportation, bathing, dressing lower body, locomotion, transfer to the toilet, and toilet use; maximal assistance for managing finances, managing medications, personal hygiene, dressing upper body, and bed mobility; and extensive assistance for phone use and eating. A tasking tool was used to determine that she required 59.33 hours of aide service per week.
The patient's oncologist provided a letter of support. Her oncologist recommended that she be turned and positioned every 2 hours.
The patient's daughter provided a letter of support. Her daughter stated the patient is bed bound and frequently incontinent of bladder and bowel. She stated that her mother has recurrent diarrhea due to systemic chemotherapy; she has developed sacral decubitus ulcers and bedsores due to frequent fecal incontinence. Her daughter stated she needs to be turned and repositioned every 2 hours and needs assistance with transferring to the commode and changing adult diapers throughout the night.  Per overnight care logs, the patient required assistance with toileting and turning approximately every 2-4 hours throughout those nights.
At issue is the medical necessity of an increase in Consumer Directed Personal Assistance Services (CDPAS) from 24 hours per day (Live-In) to 24 hours per day (Split-Shift).

The requested health service/treatment of increase in Consumer Directed Personal Assistance Services (CDPAS) from 24 hours per day (Live-In) to 24 hours per day (Split-Shift) is medically necessary for this patient.
Per NY Codes, Rules, and Regulations section 505.14, a live-in personal care aide must be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep. An aide to this patient would be unable to receive five hours of uninterrupted sleep for two reasons. First, the patient's Oncologist documented the need for the patient to be turned and positioned every 2 hours, which is typically recommended for the purpose of preventing pressure injuries. As noted in "Pressure Injuries: Prevention, Evaluation, and Management," prevention measures in patients at increased risk of pressure injuries including keeping skin clean (particularly following incontinence events) and encouraging patients to change positions often, with assistance if necessary. Increased moisture from urine, stool, and sweat can cause skin maceration and escalate the risk of pressure injuries, so incontinence supplies must be changed frequently in order to keep skin clean and dry. Secondly, the overnight care logs provided by the patient's aide show that the patient requires assistance with toileting, changing incontinence supplies, or positioning every 2-4 hours. Therefore, split-shift care is required to meet the patient's documented frequent care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies.