Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Dementia.

Treatment: Customer Directed Personal Assistance Services, 7 days per week two 12 hour shifts per day (split-shift).

The insurer denied coverage for Customer Directed Personal Assistance Services, 7 days per week two 12 hour shifts per day (split-shift).

The denial is overturned.

This is a female patient with a medical history of dementia, transient ischemic attack (TIA), rheumatic mitral insufficiency, end-stage heart failure, congestive heart failure, anxiety, coronary heart disease, depression, stroke, difficulty walking, hypertension, fecal urgency, urge incontinence, history of falls, hypothyroidism, insomnia, muscle weakness, generalized osteoarthritis, and wandering. The patient lives alone and has been receiving Consumer Directed Personal Assistance Services (CDPAS) 84 hours per week. The patient's daughter requested CDPAS, 7 days per week, two 12 hour shifts per day (split shift), which was denied; the insurer approved 24-hour live-in services. 

The patient has an extensive medical history and substantial functional impairment. The patient has several medical conditions that most likely contribute to her cognitive and physical impairment and functional decline. The functional assessment documented in the Uniform Assessment System (UAS) report indicated that the patient was totally dependent or needed maximal assistance for all instrumental activities of daily living (IADLs), except managing medications (extensive assistance). For activities of daily living (ADLs), it was noted that the patient does not walk (transported in a wheelchair), and is totally dependent or needs maximal assistance for all ADLs, except personal hygiene and bed mobility (which was extensive assistance) and eating (which was supervision). The UAS assessment of the patient's cognition indicates that the patient has impaired decision making for daily tasks; and short term and procedural memory impairment. 

According to UAS documentation, the patient always has a caregiver with her, i.e., the CDPAS aide, the daughter, or a privately hired aide. For this patient, 24-hour care helps to decrease the occurrence of falls by providing the patient with assistance for mobility when needed. As per the New York State (NYS) regulations for personal care services, in order to qualify for 24-hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can expect to have 5 uninterrupted hours of sleep within an 8 hour sleep period each day. If the patient's care needs are of such high frequency that the aide cannot have this amount of sleep on a regular basis, then continuous services are indicated, i.e., split shift. Considering the patient's medical history and progressive functional decline, it is considered medically necessary for the patient to have a caregiver present throughout the day and night to assist with all her activities of daily living. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

Based on a review of the medical record and literature, the medical necessity for CDPAS, 7 days per week, two 12 hour shifts per day (split-shift) is substantiated. The insurer's denial should be overturned.