Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: stroke with right sided hemiplegia, metastatic breast cancer, dementia, glaucoma, cataract, carpal tunnel syndrome, and osteoporosis
Treatment: Consumer Directed Personal Assistance Services (CDPAS) ; 24 Hour Continuous Care 7 Days Per Week (health plan approved 49 hours/week)
The insurer denied the Consumer Directed Personal Assistance Services (CDPAS) ; 24 Hour Continuous Care 7 Days Per Week (health plan approved 49 hours/week)
The denial is overturned, in part.

The patient is a female. Her conditions include a stroke with right sided hemiplegia, metastatic breast cancer, dementia, glaucoma, cataract, carpal tunnel syndrome, and osteoporosis. She lives with her husband, but he is unable to provide overnight informal care. Denial of Consumer Directed Personal Assistance Services (CDPAS) 24-hour continuous care 7 days per week, is being appealed. The health plan approved 49 hours per week.

Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, transportation, bathing, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility; and extensive assistance with eating. The patient has occasional bowel and bladder incontinence.

An appeal statement notes the patient has several chronic conditions and is wheelchair bound. It notes the patient needs assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation. There has been a decline in her functioning between UAS (Uniform Assessment System) evaluations completed. She requires continuous care to keep her safe in her home. The family cannot provide informal support.

A letter from the patient's provider notes the patient has stage 4 cancer and advanced dementia with frequent falls. The provider recommends 24 hour care.

A letter from another provider notes the patient has metastatic breast cancer. She has recently deteriorated physically and cognitively. She is having frequent falls. The provider recommends 24 hour care.

A letter from the patient's child notes that the patient's dementia is advancing. She has become less mobile since diagnosis of metastatic cancer in the spine. She had a series of strokes resulting in aphasia and difficulty controlling her extremities. She has had accidents overnight.

Yes, in part. The Consumer Directed Personal Assistance Services (CDPAS) ; 24 Hour Continuous Care 7 Days Per Week, is medically necessary, in part.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient, in part.
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 CDPAS (consumer directed personal assistance service) 24-hour continuous care 7 days per week, is being appealed. The health plan approved 49 hours per week.

This patient has multiple chronic medical conditions, including metastatic breast cancer and dementia. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). She has occasional bowel and bladder incontinence. Appeal statements note there has been a decline in the patient's cognition and functional status. She is having frequent falls. Her family cannot provide informal support. Caregiver logs are provided for review, but do not include information regarding nighttime care. This patient has significant limitations and requires significant assistance with ADLs (activities of daily living) and personal care. The approved CDPAS (consumer directed personal assistance service) 49 hours per week is insufficient to meet the patient's needs. The information provided does not support continuous care, as there is no evidence of the patient requiring a frequency of care where the aide would unlikely get five hours daily of uninterrupted sleep during the aide's shift. The proposed increase in CDPAS (consumer directed personal assistance service) 24-hour continuous care 7 days per week is medically necessary, in part. Specifically CDPAS (consumer directed personal assistance service) 24-hour live in is medically to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care.