Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Suicidal ideation, cannabis use disorder, ADHD (attention deficit hyperactivity disorder), PTSD (post-traumatic stress disorder), GAD (general anxiety disorder), agoraphobia, asthma, and autism spectrum.
Treatment:  Increase Consumer Direct Personal Assistance to 168 Hours/Week, 12 Hours x 2 x 7 Days, Split Shift.

The insurer denied the Increase Consumer Direct Personal Assistance to 168 Hours/Week, 12 Hours x 2 x 7 Days, Split Shift.  The denial is upheld.

The patient is a female. Her conditions include suicidal ideation, cannabis use disorder, ADHD (attention deficit hyperactivity disorder), PTSD (post-traumatic stress disorder), GAD (general anxiety disorder), agoraphobia, asthma, and autism spectrum.  Denial of increase consumer direct personal assistance (CDPAS) to 168 hours/week, 12 hours x 2 x 7 days, split shift, is being appealed. The Plan has approved 21 hours per week.

Additional hours were requested because the patient does not sleep well, it takes longer to get things done during the day, she requires assistance with ambulation, and constantly falls.  Uniform Assessment System (UAS) evaluation shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medications,  and bathing; limited assistance with personal hygiene, lower body dressing, and toilet transfer; and supervision with upper body dressing, walking, locomotion, bed mobility and eating.  She was observed to ambulate without an assisted device.  She has occasional bladder incontinence.  She falls frequently and is able to get herself up.

An appeal letter from the patient's provider notes the patient is unable to perform ADLs (activities of daily living), has an unsteady gait, and is at risk for falls.

An appeal statement from the patient's advocate notes the patient has limited verbal communication, impaired memory, and poor coordination.  States the patient needs nighttime assistance with toileting.

No, the Increase Consumer Direct Personal Assistance to 168 Hours/Week, 12 Hours x 2 x 7 Days, Split Shift, 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. Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase CDPAS (consumer directed personal assistance services) to 168 hours/week, 12 hours x 2 x 7 days, split shift. The Plan has approved 21 hours per week.

This patient is on the autism spectrum. Continuous care was denied based on UAS (Uniform Assessment System) evaluation and showing the patient can direct her own care, is able to ambulate with assistive device, is able to turn herself in the bed and does not have 24-hour care needs, such as turning every 2 hours. UAS (Uniform Assessment System) evaluation completed shows the patient requires limited assistance with personal hygiene, lower body dressing, and toilet transfer; and supervision with upper body dressing, walking, locomotion, bed mobility and eating. She has occasional bladder incontinence. She falls frequently due to poor coordination but can get herself up. Appeals note the patient needs 24-hour care to assist with ADLs (activities of daily living), including nighttime toileting, and she is a fall risk. The documentation provided does not support that the patient requires continuous care. There is no evidence of skin breakdown and need for turning/repositioning every 2 hours. Personal care services are not indicated when no tasks are being performed or for supervision. The approved CDPAS (consumer directed personal assistance service) 21 hours per week is appropriate to meets the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase to 168 hours/week, 12 hours x 2 x 7 days, split shift is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.