Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: hypertension, diabetes and kidney disease

Treatment: Increase in Consumer Directed Personal Services (CDPAS) from 7 days per week, 12 hours per day; 84 hours per week to 7 days per week, 24 hours per day of continuous care by more than 1 person; 168 hours per week

The insurer denied coverage for increase in Consumer Directed Personal Services (CDPAS) from 7 days per week, 12 hours per day; 84 hours per week to 7 days per week, 24 hours per day of continuous care by more than 1 person; 168 hours per week

The denial is modified.

 
This is an elderly female with chronic medical problems including hypertension, diabetes and kidney disease. The request is for an increase from Consumer directed personal assistance services (CDPAS) 7 days per week, 12 hours per day; 84 hours per week to 7 days per week, 24 hours per day of continuous care by more than 1 person; 168 hours per week; leading to an external review. 

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as minimally impaired. She reportedly requires maximal assistance to total dependence for completing Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, lower body dressing and toilet use. Extensive assistance is reportedly needed for personal hygiene, upper body dressing, locomotion, toilet transfer and ambulation. Limited assistance is reported needed for eating and bed mobility. The patient is reportedly frequently incontinent of bladder and occasionally incontinent of bowel. Her ability to perform activities of daily living (ADL) tasks and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. There has been 1 reported fall over the prior 30 days. According to the report, the family has "private pay for night aide." 

The patient's cognitive status and particularly her functional ability have declined when compared to the prior UAS reports. The patient had been essentially at the limited assistance level to independent for performing much of her ADL tasks, which have declined to extensive and maximal assistance. 

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. Contrary to the assertions of her doctor, based on the documents reviewed which also document the durable medical equipment (DME) provided by the insurer, a live-in CDPAS is likely capable of consistently obtaining approximately 5 hours of uninterrupted sleep over the course of a 24 hour shift.  Based on the documents reviewed, the patient's functional and home care needs are more appropriately provided and maintained by increasing CDPAS to 24 hours per day, 7 days per week (Monday through Sunday) live-in.

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 an increase in Consumer Directed Personal Services (CDPAS) from 7 days per week, 12 hours per day; 84 hours per week to 7 days per week, 24 hours per day of continuous care by more than 1 person; 168 hours per week services is not substantiated. However, increasing CDPAS to 24 hours per day live-in, 7 days per week (Monday through Sunday) is medically necessary.