Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care/ Increase in Consumer Directed Personal Assistant Program (CDPAP) services: continuous care (split shift) services- 7 days x 24 hours (split shift) per week. 

The insurer denied Increase in Consumer Directed Personal Assistant Program (CDPAP) services: continuous care (split shift) services- 7 days x 24 hours (split shift) per week. The denial is upheld. 

The patient is a female with a past medical history significant for transient ischemic attack (TIA), impaired coordination, pain with ambulation, vascular dementia, depression, anxiety, insomnia, fatigue, ischemic cardiomyopathy, hypertension, hyperlipidemia, diabetes mellitus, cerebrovascular disease, and chronic pain syndrome. The patient has worsening physical and cognitive disabilities based upon the evaluations. The patient is able to ambulate with a walker. The patient is requesting consumer program services, continuous care, split shift 7 days a week times () 24 hours a day for which services were denied based upon medical necessity. The patient is appealing the decision. 
At issue is the medical necessity of Increase in Consumer Directed Personal Assistant Program (CDPAP) services: continuous care (split shift) services- 7 days x 24 hours (split shift) per week. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Increase in Consumer Directed Personal Assistant Program (CDPAP) services: continuous care (split shift) services- 7 days x 24 hours (split shift) per week is not medically necessary for this patient. 

This patient has multiple medical problems with worsening physical and cognitive disabilities. However, the documentation provided including the Uniform Assessment System (UAS), physician notes and appeal letter failed to demonstrate a medical need above and beyond what a 24-hour live-in aide could provide. Specifically, there was no reason noted why a live-in aide could not perform these services. There is no notation of why the patient would need more than 16 hours a day of care and that the aide could not get proper rest defined as at least 5 hours of uninterrupted sleep. Specifically, the aide must be performing a service such as an activities of daily living (ADL) or Instrumental activities of daily living (IADL). Aide services for watching the patient in the middle of the night without actually performing a medically necessary ADL would be considered observation and typically not a provided service. The documentation provided did not note specific needs for 12 hours a day  7 days a week split shift. No specific log was presented for review which documents nighttime needs, and why a live-in aid would not be appropriate in this situation. There is insufficient data to support split shift services versus (vs) live-in services. He has intermittent unscheduled needs which may be addressed through live-in services. 

Therefore, the requested health service/treatment of Increase in Consumer Directed Personal Assistant Program (CDPAP) services: continuous care (split shift) services- 7 days x 24 hours (split shift) per week is not medically necessary.