Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, depression and anxiety. 
Treatment: Consumer Directed Personal Assistance Service Hours From 49 Hours a week to 7 Days A Week 24 Hours A Day (live-in). 

The insurer denied the Consumer Directed Personal Assistance Service Hours From 49 Hours a week to 7 Days A Week 24 Hours A Day (live-in). 
The denial is overturned. 

The patient is a female with medical conditions including dementia, depression and anxiety. She lives alone. Denial of increase consumer directed personal assistance program (CDPAP) hours from 49 hours a week to 7 days a week 24 hours a day, live-in. 

Uniform Assessment System (UAS) evaluation completed, shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing medications, phone use, bathing and toilet use; extensive assistance with personal hygiene, and dressing; limited assistance with waking, locomotion, and bed mobility; and supervision with eating. She ambulates with a walker. She has frequent bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in bathing, personal hygiene, toileting and bed mobility. 

The patient's nephew reports that the patient has unsafe behavior, including wandering outside and forgetfulness. 

An appeal statement notes the patient has recent deterioration in her physical and mental conditions. She requires cuing and supervision to complete ADLs (activities of daily living), including nighttime toileting, transferring, and hygiene. 

An appeal letter from the patient's provider notes the patient needs assistance with all ADLs (activities of daily living). Notes the patient wakes up frequently at night and is a fall risk. Recommends 24 hour home aide. 

Personal care logs are provided showing the patient becomes agitated at night. She is put to bed and she awakens 4-5 hours later, is agitated, and found to have a wet diaper. She awakens again 5 hours later. 

Yes, the requested increase in consumer directed personal assistance program to 7 days/week, 24 hours/day, live-in, 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. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase consumer directed personal assistance service hours from 49 hours a week to 7 days a week 24 hours a day, live-in is being appealed. 

Nurse assessments were performed twice. Uniform Assessment System (UAS) evaluation completed most recently shows the patient needs assistance with all ADLs (activities of daily living), except eating. She has frequent bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in bathing, personal hygiene, toileting and bed mobility. Appeal statements note the patient has deterioration in her physical and mental functioning. Patient care logs show the patient requires assistance with toileting during nighttime. This patient requires significant assistance with ADLs (activities of daily living) and personal care. Her physical functioning as deteriorated between UAS (Uniform Assessment System) evaluations completed. The approved consumer directed personal assistance program 49 hours per week is insufficient to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase in CDPAP (consumer directed personal assistance program) to 7 days a week 24 hours a day, live-in, is medically necessary. 

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