Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia s/p (status post) stroke
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) services for a total of 168 hours/week (split shift)
The insurer denied the increase in CDPAP services for a total of 168 hours/week (split shift).
The denial is overturned.

The patient is a male. His conditions include dementia and stroke with left-sided hemiplegia, osteoarthritis arthritis, ataxia, neuropathic bladder, and heart failure. Denial of an increase in consumer directed personal assistance program (CDPAP) services for a total of 168 hours/week, split shift, is being appealed. The health plan approved CDPAP 8.5 hours/day, 7 days/week, for a total of 59.5 hours/week.

The patient's Uniform Assessment System (UAS) evaluation completed showed moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, phone use, shopping, and locomotion; maximal assistance with transportation, bathing, personal hygiene, dressing, walking, toileting, bed mobility, and eating. The patient has bowel and bladder incontinence. Compared to UAS evaluation completed previously, there has been a decline in cognition, toilet use, locomotion, eating, and bed mobility.

A letter from the patient's provider notes the patient has rapidly declining mental and physical health. The patient has several chronic conditions as already noted above. He has a history of repeated falls. He was recently hospitalized. He needs assistance with ADLs (activities of daily living) and daily human supervision. A letter from the patient's wife notes his condition has declined since the stroke. He needs assistance with ADLs as already accounted for in the UAS evaluation. He has nighttime needs including assistance with using the restroom every two hours. He had falls twice in the past year. Logs are provided showing frequent overnight assistance with transfers, toileting, and positioning.

An appeal statement notes the patient has several chronic conditions and needs assistance with ADLs as already accounted for. This includes overnight needs that require maximal assistance. He needs assistance with turning/repositioning. Logs referenced show frequent assistance with toileting and repositioning throughout the night.

Yes, the increase in CDPAP  Services for a total of 168 hours/week (split shift) 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 five hours daily of uninterrupted sleep during the aide's shift. Denial of an increase in CDPAP services for a total of 168 hours/week, split shift, is being appealed. The health plan approved CDPAP 8.5 hours/day, 7 days/week, for a total of 59.5 hours/week.

This patient has multiple chronic conditions. UAS evaluation completed showed the patient requires maximal assistance to total dependence with all ADLs. He is incontinent of bowel and bladder. Compared to UAS evaluation completed previously, there has been a decline in cognition, toilet use, locomotion, eating, and bed mobility. The appeal statements support the patient is dependent with all ADLs and requires frequent assistance with toileting, transfers, and turning/repositioning. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved CDPAP services for a total of 168 hours/week, split shift, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.