Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke, cognitive impairment, spinal stenosis, chronic obstructive pulmonary disease (COPD), schizophrenia, bipolar disorder, and Parkinson's. 
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Services to Split Shift for a Total of 168 Hours per Week
The insurer denied: Increase Consumer Directed Personal Assistance Program (CDPAP) Services to Split Shift for a Total of 168 Hours per Week
The denial is upheld.

This elderly patient has medical conditions that include strokes, cognitive impairment, spinal stenosis, chronic obstructive pulmonary disease (COPD), schizophrenia, bipolar disorder, and Parkinson's. The denial of an increase in consumer directed personal assistance program (CDPAP) services to a split shift for a total of 168 hours per week is being appealed. The health plan approved 7.5 hours per day, 7 days per week, for a total of 52.5 hours per week. Uniform Assessment System evaluation performed six months ago shows moderately impaired cognition and functional status requiring extensive assistance to total dependence with all activities of daily living, except limited assistance with eating. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with all areas of functioning. The patient has occasional bladder incontinence. A letter from the Provider notes the patient has a history of falls. He is not safe at home without 24-hour supervision due to memory loss. A letter from another Provider notes the patient has psychosis and memory issues. He gets up in the middle of the night to go to the bathroom and needs assistance. A letter from a Nurse Practitioner (NP) notes the patient's tremors impact his ability to care for himself. He is at risk for falls. He is in need of increased observation.

The proposed treatment is not 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. 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. This patient has multiple chronic conditions. The denial of an increase in consumer directed personal assistance program (CDPAP) services to split shift for a total of 168 hours per week is being appealed. The health plan approved 7.5 hours per day, 7 days per week, for a total of 52.5 hours per week. Uniform Assessment System evaluation performed six months ago shows the patient requires maximal assistance to total dependence with all activities of daily living. He is incontinent of bladder. Compared to Uniform Assessment System evaluation completed last year, there has been a decline in all areas of functioning. The appeal statements recommend additional hours for supervision. The information provide show that this patient has significant limitations in functioning that have declined. However, the information does not support that the patient has needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift, such as turning/repositioning and toileting every two to three hours. The proposed increase in consumer directed personal care program services from 52.5 to 168 hours per week, split shift, is not medically necessary.