Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, osteoporosis, hypertension, and coronary heart disease
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week
The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week.
The denial is overturned.

This is a geriatric patient with a history of dementia, osteoporosis, hypertension, and coronary heart disease. The Uniform Assessment System was completed due to a reported significant change in status. The patient lives alone.

Per the cited references, personal care services are the provision of some or total assistance with personal hygiene, dressing, and feeding and nutritional and environmental support. The services must be essential to the maintenance of the patient's health and safety in their home, be ordered by physician or nurse practitioner, and be based on an assessment of the patient's needs for the service in accordance with guidelines. Allotment of time separate and apart from personal care tasks authorized is not required for safety monitoring. However, there is a clear and legitimate distinction between safety monitoring as a nonrequired stand-alone function while no personal care services are being provided and the appropriate level of safety monitoring while the patient is receiving assistance with personal care services such as transferring, toileting, or walking. The use of personal assistance is crucial for patients with disabilities to allow them to remain in the community as opposed to being placed in institutional settings. 

Patients who require uninterrupted care by more than 1 personal care aide for more than 16 hours in a calendar day may be appropriate for 24-hour split shift services when a personal care aide is unable to obtain 5 hours daily of uninterrupted sleep during the 8-hour sleep schedule. In this case, the patient had a significant decline in status. The patient could no longer independently perform activities of daily living. The patient required daily assistance with reminders, preparation and administration of medications and meals 3 times daily, self-care, household chores, grocery shopping, transportation, and assistance with multiple daily and nightly changes of soiled diapers and linens. There was increasing disorientation and hallucinations. The family reported that the patient was now bedbound. The requested increase in hours for a total of 168 weekly hours is medically necessary for the patient. The documentation identified that the patient needed assistance with transfers, walking, and toileting. The activities are not limited to 12 hours/day. It is usual for nighttime toileting needs to increase as a person ages. For patients with dementia, their nighttime behaviors can be unpredictable. The patient required extensive weightbearing assistance to transfer, walk, and use the toilet. The family indicated a significant decline in cognitive and functional abilities to the point that the patient was mostly bedbound. A caregiver at night that is not asleep is needed to aid with activities of daily living. The patient requires routine diaper changes at night that would not allow a caregiver to get uninterpreted 5 hours of sleep. 

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 in Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is substantiated.