Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular Dementia
Treatment: Consumer Directed Personal Assistance Program (CDPAP) 12 hours/day, 7 days/week, a total of 84 hours/week
The insurer denied CDPAP 12 hours/day, 7 days/week, a total of 84 hours/week.
The determination is overturned.

This is a female patient with a medical history notable for vascular dementia and incontinence. The patient is approved for 9.5 hours/day, 7 days/week, for a total of 66.5 hours/week of consumer directed personal assistance program (CDPAP). The patient and her care team requested an increase to 12 hours/day, 7 days/week, for a total of 84 hours/week, and this request was denied by the health plan.

The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient is in need of increased care and support for her basic daily needs. Due to her vascular dementia, she is unable to complete activities of daily living (ADLs) without assistance. She has developed urinary incontinence and is unable to change or clean herself after episodes of incontinence. She also requires assistance with walking and hygiene. She is unable to direct her own care or call for help in the event of an emergency. She requires prompting for eating and for taking medications. Due to all of these concerns, they recommend a minimum of 12 hours/day to meet the patient's personal care needs.

Office visit notes from a telemedicine visit were provided and reviewed. They discussed the patient's extensive medical history. The family is providing for additional aide hours out of pocket because they state that the patient is doing very poorly and is unable to walk. Her speech has become nonsensical. She was noted to be very physically weak. She requires prompting for eating and all other ADLs. She was having extensive difficulty with sleep.

A Uniform Assessment System (UAS) was completed. The patient lives with her spouse in a private home. Her cognition was severely impaired. She was alert and oriented to person only during the assessment. She occasionally experiences times of agitation. Her speech was nonsensical. For her instrumental activities of daily living (IADLs), she requires total dependence or maximal assistance for all. For her ADLs, she requires total dependence for toilet use. She requires maximal assistance for bathing, hygiene, dressing, toilet transfer, bed mobility, and eating. She requires extensive assistance for walking and locomotion. She is frequently incontinent of both urine and stool. She wears pull-ups for incontinence care. There was no pressure ulcer present at the time of the evaluation. Compared to a prior assessment, the patient showed a cognitive and functional decline. At issue is the medical necessity of CDPAP 12 hours/day, 7 days/week, a total of 84 hours/week.

The requested health service of CDPAP 12 hours/day, 7 days/week, a total of 84 hours/week is medically necessary for this patient.

The patient requires personal care assistance for all ADLs. Her dementia is severe and she is unable to direct her own care. She has incontinence and is unable to manage her own incontinence care products. Her personal care needs are expected to be continuous and unscheduled throughout the day. The requested modest increase to 12 hours/day should allow her for full daytime coverage from her personal care aide. This request is medically necessary and reasonable for the patient. Failure to address her personal care needs could result in falls, skin breakdown, and or infection.