Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hip fracture, hypertension, stroke and atrial fibrillation

Treatment: Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 24 Hour(s) per Day (Split Shift)

The insurer denied coverage for Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 24 Hour(s) per Day (Split Shift).

The denial is modified.

This is an elderly female with chronic medical problems including hypertension, stroke and atrial fibrillation. She sustained a left hip fracture, underwent surgical repair and subsequently transferred to a skilled nursing facility. She currently lives with her daughter in a private residence. The insurer approved consumer directed personal assistance services (CDPAS) 63 hours/week and the request is for CDPAS 24 hours a day, 7 days a week (split shift), totaling 168 hours per week; leading to an external review.

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as moderately impaired. She is totally dependent for completing Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is also reportedly total dependent for bathing, lower body dressing, locomotion (uses wheelchair) and toilet use. Maximal assistance is reportedly needed for personal hygiene, upper body dressing and toilet transfer. Extensive assistance is reportedly needed for bed mobility and eating. The patient is frequently incontinent of bladder and occasionally incontinent of bowel.

The patient's cognition and functional ability have declined when compared to the prior UAS report.  An office visit note from the orthopedic surgeon was reviewed. The patient was "4 months status post left femur intramedullary nail. She is overall progressing well." The patient was "able to stand with assistance and walk with assistance." Her surgical wounds were "well-healed." The surgeon recommended "outpatient physical therapy." In an addendum, after receiving a call from the patient's daughter, the surgeon subsequently recommended "continuation of home care services with extended hours until the patient is safely able to ambulate independently and perform her activities of daily living."

Based on the enclosed clinical documents, the patient does not have a medical condition, functional incapacity or level of care that requires the requested CDPAS 24 hours a day, 7 days a week (split shift), totaling 168 hours per week. This physician would agree that the patient may benefit from additional monitoring; particularly due to her weakness, functional decline and falls risk. However, safety monitoring under CDPAS does not include monitoring an individual (e.g., with dementia, falls risk, general weakness) when no other Level I or Level II personal care services task is being provided. This physician would also agree that the patient's functional ability has declined and supports an increase in CDPAS. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained at home by increasing CDPAS 12 hours/day, 7 days/week for a total of 84 hours/week in addition to continuing shared household responsibilities of the other adult living in the home and informal care from family.


Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 24 Hour(s) per Day (Split Shift) services is not substantiated. However, increasing CDPAS to 12 hours/day, 7 days/week for a total of 84 hours/week is medically necessary.