Appeal type: Medical necessity
Decision: Overturned

Diagnosis: PD, OA, joint contractors, dementia, anxiety, HTN, DM, MDD, dysphagia, muscle weakness, urinary incontinence, and adult failure to thrive
Treatment: Increase Consumer Directed Personal Assistance Services (CDPAS) From Mutual Live-in to 24 Hours Per Day (Split Shift), Pre-service
The insurer denied the Increase Consumer Directed Personal Assistance Services (CDPAS) From Mutual Live-in to 24 Hours Per Day (Split Shift), Pre-service 
The denial is overturned.

The patient is a male with several medical conditions, including Parkinson's disease, OA (osteoarthritis), joint contractors, dementia, anxiety, HTN (hypertension), DM (diabetes mellitus), MDD (major depressive disorder), dysphagia, muscle weakness, urinary incontinence, and adult failure to thrive.  The subject of this appeal is the denial of Consumer Directed Personal Assistance Services increase to 24 hours per day, split shift.  The patient has been approved for mutual 24 hours/day live in Consumer Directed Personal Assistance Services.

Assessment performed shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, bathing, and lower body dressing; maximal assistance with managing medications, personal hygiene, and upper body dressing; and extensive assistance with bed mobility and eating.  The patient uses a wheelchair and scooter for locomotion.  He is wheelchair- and bed-dependent.  ADLs (activities of daily living) and IADLs (instrumental activities of daily living) are performed in bed. He has bowel and bladder incontinence.  Compared to the previous assessment, the patient needs a higher level of assistance with managing finances and lower body dressing.

An appeal letter from NY (New York) State Ombudsman program states the patient requires nighttime assistance with turning and positioning and toileting that would not allow a live-in aid to obtain five hours of uninterrupted sleep. His PCP (primary care provider) has ordered repositioning every two hours to prevent bed sores.  A letter from his provider states the patient has decubitus ulcer and needs assessment for possible wound care.  The provider states the patient needs to be turned every two hours.

Yes, the Increase Consumer Directed Personal Assistance Services (CDPAS) From Mutual Live-in to 24 Hours Per Day (Split Shift) is medically necessary.
Medically necessary services are those which are:
1)	safe 
2)	effective
3)	generally accepted national standard of medical practice 
4)	not provided primarily for convenience of the patient or the practitioner 
5)	the least intensive and/or most appropriate alternatives among diagnostic and treatment options.


The proposed treatment is medically necessary, because it is consistent with generally accepted national standard of medical practice.

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 provider five hours daily of uninterrupted sleep during the aide's shift.  This patient has dementia and physical limitations resulting in him being bedbound.  He requires assistance with all ADLs/IADLs (activities of daily living/instrumental activities of daily living), which are performed in the bed.  Assessment performed shows deterioration in the patient's physical functioning compared to assessment performed previously.  In addition to functional limitations, the patient is incontinent of bowel and bladder.  He has decubitus ulcers and requires turning and repositioning every two hours.  The frequency of care, including repositioning every two hours would interfere with the aide's ability to obtain five hours daily of interrupted sleep.  Therefore, the Increase Consumer Directed Personal Assistance Services (CDPAS) From Mutual Live-in to 24 Hours Per Day (Split Shift) is medically necessary.