Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 24 Hours a day, 7 Days a week-(Split-Shift). 
The insurer denied Consumer Directed Personal Assistance Services (CDPAS) 24 Hours a day, 7 Days a week-(Split-Shift). 
The determination is overturned. 

The patient is a female with medical history notable for congestive heart failure, advanced dementia, prior stroke, poor vision, and wheelchair dependent status. The patient is approved for 84 hours per week of consumer directed personal assistance services. The patient and her care team requested an increase to 24-hour per day, two 12-hour split shifts, 7 days per week for a total of 168 hours per week. This request was denied by the health plan. 
The patient's primary care physician provided a letter of support for this appeal. The letter states that the patient is homebound and bed bound and requires personal care throughout the day and night. She specifically requires assistance with toileting, transfers, turning and repositioning every 2 hours, locomotion, bathing, dressing, grooming, and other tasks. The letter states that due to the patient's needs for toileting and turning and repositioning throughout the night, a live-in personal care aide would not be able to sleep at least 5 hours consecutively and for 8 hours at night. Additionally, the physician notes that the patient has no formal or informal support outside of her personal caregiver. 
Night time caregiver logs were provided for review. The patient requires assistance with toileting at unscheduled and unpredictable times throughout the night. She also requires assistance with repositioning. There were no 5-hour gaps in her care overnight.
A Uniform Assessment System (UAS) was completed.  The patient lives alone in a one-bedroom apartment. Her cognition was severely impaired. She was alert and oriented to self only and occasionally not oriented at all. She is confused most of the time and not able to direct her own care. For her instrumental activities of daily living, she requires total dependence for all. At issue is the medical necessity of Consumer Directed Personal Assistance Services (CDPAS) 24 Hours a day, 7 Days a week-(Split-Shift). 
The requested health service of Consumer Directed Personal Assistance Services (CDPAS) 24 Hours a day, 7 Days a week-(Split-Shift) is medically necessary for this patient. 
The patient's personal care needs are extensive, as she requires caregiver assistance to complete all activities. She has advanced dementia and cannot direct her own care. She is incontinent of both urine and stool and not capable of directing or managing her incontinence care. Her personal care needs can be expected to be continuous and unscheduled throughout the day and night. Night time care logs demonstrate that a live-in caregiver would not be able to receive adequate rest at night. This is further supported by the documentation from the patient's primary care physician. Therefore, the requested service of continuous 24-hour care with two 12-hour split shifts is medically necessary for the patient. Failure to address the patient's personal care needs could result in skin breakdown, infection, and/or injury.