Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: CDPAP services at 24 hours per day (split shift), 7 days a week for a total of 168 hours per week. 

The insurer denied CDPAP services at 24 hours per day (split shift), 7 days a week for a total of 168 hours per week. 

The determination is overturned. 

The patient has a past medical history of a cerebrovascular accident (CVA) with left hemiparesis, congestive heart failure, hyperlipidemia, colon cancer, diabetes mellitus (DM) type 2, coronary artery disease, hypertension, chronic kidney disease, anemia, atrial flutter, gout, wheelchair bound status, Alzheimer's disease, urinary incontinence, and bowel incontinence who had been assigned Consumer Directed Personal Assistance Services (CDPAS) 9.5 hours/day, 7 days/week, to total 66.5 hours/week based on an assessment tool. At the assessment, the patient was assessed at total assistance with tasks of ordinary housework, managing finances, managing medication, phone use, stairs, shopping, transportation, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use while maximal assistance with tasks of meal preparation, personal hygiene, dressing upper body, and bed mobility. The patient was assessed at extensive assistance with task of eating. 

Notes from the assessment stated the patient's Mini-Mental State Examination (MMSE) was 15/30, that he lived with his ex-wife in a two bedroom apartment, that he required a Hoyer lift for all transfers, and was wheelchair bound. There was a request to increase CDPAS to 24 hours/day, split-shift, 7 days/week. The patient had a telephonic assessment tool performed noting no change in assistance needs with activities of daily living (ADL)/ Instrumental activities of daily living (IADL) tasks compared to the previous assessment tool. The noted reason for the assessment was "significant change in status". It was noted the patient still required a Hoyer lift for all transfers and was wheelchair bound. The MMSE was not documented in notes provided. The insurer sent final adverse determination notice denying the request to increase CDPAS services stating the request was not medically necessary and the patient did not meet criteria. The denial notice documented that the son had requested a plan appeal regarding the initial adverse decision as the patient required additional assistance and the (ex) spouse cannot care for him. The denial notice further stated the patient's abilities to perform physical functioning stayed the same, therefore CDPAS hours stay the same. 

In addition, the denial notice stated the UAS did not support nighttime hours and additional hours are not provided for supervision, companionship, and when tasks are not being performed by the aide. The patient/family appealed the denial decision. The patient's primary care physician (or provider) (PCP) provided a letter outlining the patient's medical diagnoses including two debilitating strokes, the most recent, leaving him wheelchair bound and with left-sided hemiparesis. The letter further stated the patient would be moving into a senior building for those who are disabled and consequently the patient will need 24 hour support and assistance as he would be residing alone and is unable to care for himself. In addition, the letter stated the patient's Alzheimer's disease was causing deterioration of cognitive function with the need for prompting, direction, and assistance from a home attendant. The letter also stated the patient is incapacitated to a point where he is unable to articulate when he needs help, requires assistance throughout the night with going to the bathroom, and requires assistance in taking medication as he is left alone when CDPAS is not present. Finally, the letter stated it was medically necessary for the patient to have 24 hour CDPAS care. The PCP appealed the denial. At issue is the medical necessity of CDPAP services at 24 hours per day (split shift), 7 days a week for a total of 168 hours per week. 

The services are medically necessary. The patient has a documented past medical history of a Cerebrovascular accident (CVA) times two (x 2) with left hemiparesis, wheelchair bound status, and cognitive decline (MMSE 15/30 Uniform Assessment System (UAS)) with the lack of informal help due to a move into a senior building for those who are disabled. The patient has 24 hour care needs, requiring assistance with all ADLs/IADLs, including bed mobility, transfer toilet, toilet use, and incontinence cares in the overnight hours. The patient has unpredictable and unscheduled care needs and the plan failed to document a plan of care for these unpredictable and unscheduled care needs. The insurer cites lack of change in assistance with ADL/IADL tasks between the assessment tools as one of the reasons for denial of increased services, however, the patient's level of assistance on the  assessment was appropriate at 24 hours/day but at that time the patient had informal help with all tasks when the CDPAS was not present. The patient has 24 hour care needs. The patient previously had informal help with his ex-wife and no longer has this informal help as he moved into an apartment by himself. The increase in CDPAS hours is not solely for safety and supervision but to assist the patient with safe completion of ADL/IADL tasks. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home. Given the plan's clinical standard, all information provided regarding the patient, the attending physician's statement, and the applicable and generally accepted practice guidelines, CDPAS services 24 hours/day, split-shift, 7 days/week are medically necessary for this patient.