Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's.

Treatment: Customer Directed Personal Assistance services 24 hours a day, 7 days a week (split Shift).

The insurer denied coverage for Customer Directed Personal Assistance services 24 hours a day, 7 days a week (split Shift).

The denial is overturned.

This geriatric patient has severe functional impairment associated with the medical conditions and is dependent on caregiver assistance for all Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). The patient lives alone. The Uniform Assessment System (UAS) identifies one informal helper (helps with IADLs). The patient receives personal care services provided as Consumer Directed Personal Assistance Services (CDPAS). Current services are CDPAS 16 hours per day, 7 days per week. A letter from one of the patient's sons indicated that an informal caregiver was aiding 8 hours per day; the patient was receiving 24-hour care (CDPAS 16 hours per day plus informal care 8 hours per day). The son reported that the caregiver who was providing informal care during non-CDPAS hours is no longer available. The family requested an additional 8 hours of CDPAS to maintain 24-hour care for the patient. Request for CDPAS 24 hours per day, 7 days per week (split shift) was denied. 

The most recent UAS was reviewed. Functional status for all IADLs is reported as total dependence. For ADLs, the patient is totally dependent for bathing, personal hygiene, dressing upper and lower body, toilet use, locomotion, and bed mobility. The patient needs maximal assistance for eating. It was noted that walking and transfer to the toilet did not occur during the entire period.

Managed Long Term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Therefore, all the patient's care needs during the day and night must be considered in the determination of the personal care service hours. 

The patient has no bladder or bowel control. Incontinence occurs at unplanned times of the day/night. Remaining in wet soiled diapers for extended hours increases risk of skin damage, especially in a high-risk elderly patient. The patient has chronic pain (arthritis). The patient relies on the aide for pain relief (such as reposition; assist with medication), and there is no effective means of pain relief when the patient is alone. Regarding pressure ulcers, if the patient has no help for 8 hours (current plan) or 5 hours (when live-in aide sleeps), repositioning and incontinence care cannot occur during that time, which increases risk of skin damage. The patient's ability to leave the bed unassisted is limited, but if the patient is near the edge of the bed and tries to get up, the risk of falling is high without a caregiver to assist. 

CDPAS hours are flexible, but it cannot be expected that 16 hours per day is sufficient for a person who is totally dependent for all daily activities and needs ADL care at multiple and variable times throughout the day and night. CDPAS 24 hours per day, split shift is consistent with the patient's ADL/IADL care needs and is in compliance with NYS (New York State) regulations for personal care services and CDPAS. The additional service hours are medically necessary to help prevent skin damage (due to incontinence, pressure), infection (such as UTI); help prevent falls/injury; and help relieve pain/improve patient comfort. The records provided for review support the patient's need for 24-hour continuous services (split shift).

Based on the above, the insurer's denial must be overturned. 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 increase of Customer Directed Personal Assistance services 24 hours a day, 7 days a week (split Shift) is substantiated.