Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  History of stroke with residual hemiplegia, oxygen dependent.
Treatment:  Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 24 hours per day, continuous care by more than one person, 168 hours per week, when member's mutual spouse is out of the community; and 7 days per week, 19 hours per day, mutual split shift with member's spouse for a total of 24 hours per day continuous care by more than 1 person, when member's mutual spouse is in the community.

The insurer denied Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week, when member's mutual spouse is out of the community and 7 days per week, 19 hours per day, mutual split shift with member's spouse for a total of 24 hours per day continuous care by more than 1 person, when member's mutual spouse is in the community.  The denial is overturned.

This elderly male patient has several medical conditions that include history of stroke with residual hemiplegia and speech deficit, chronic kidney disease, and oxygen dependent. The denial of Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 24 hours per day, continuous care by more than one person, 168 hours per week, when member's mutual spouse is out of the community and 7 days per week, 19 hours per day, mutual split shift with member's spouse for a total of 24 hours per day continuous care by more than 1 person, when member's mutual spouse is in the community is being appealed. The health plan approved Consumer Directed Personal Assistance Services 7 days per week, 5 hours per day, 35 hours per week. A letter from the patient's physician notes the patient has been receiving hospice care for 8 months. He is dependent with all activities of daily living (ADLs). He has nighttime needs that result in his caregiver receiving an average of 4 hours per night. Nighttime needs require frequent emptying of urinary catheter and trips to bathroom due to bowel incontinence. He becomes agitated, restless, and combative at night. The patient is unable to transfer without assistance due to weakness and unsteady gait. He has experienced a neurological decline and has a limited ability to express himself.

The proposed treatment is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide 5 hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions. He has been in hospice care for 8 months. The denial of Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 24 hours per day, continuous care by more than one person, 168 hours per week, when patient's mutual spouse is out of the community and 7 days per week, 19 hours per day, mutual split shift with patient's spouse for a total of 24 hours per day continuous care by more than 1 person, when patient's mutual spouse is in the community is being appealed. The health plan approved Consumer Directed Personal Assistance Services 7 days per week, 5 hours per day, 35 hours per week. The appeal statement from the patient's provider reports that the patient is dependent with all activities of daily living. He has nighttime needs that require frequent assistance with toileting and transfers. His nighttime needs prevent his caregiver from getting 5 hours of 
uninterrupted sleep. This member has continuous needs. The proposed increase Consumer Directed Personal Assistance Services (CDPAS) is medically necessary.