Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia other than Alzheimer's disease; Stroke/cerebrovascular accident-no active treatment

Treatment: continuation of Consumer Directed Personal Assistance Services (CDPAS) hours at 7days a week 2-12 hours a day (Split- Shift)

The insurer denied coverage for continuation of Consumer Directed Personal Assistance Services (CDPAS) hours at 7days a week 2-12 hours a day (Split- Shift). The denial was reversed.

This patient is a female with medical problems that adversely affect her ability to perform daily activities (IADLs and ADLs), including arthritis and dementia. She had previously been receiving CDPAS 7 days, 2-12 hour split shift. It was noted that the patient has moderate, intermittent pain daily, specifically noted as knee pain. This is most likely related to diagnosis of osteoarthritis. She has a slow, unsteady gait. She needs extensive assistance for walking/locomotion. She needs assistance to stand up. She uses a cane (per sleep study); and reported to be unable to use walker due to confusion.  Arthritis is a frequent cause of disability in older people and often results in loss of independence with routine daily activities. The patient needs assistance to walk which is probably a combination of physical limitations from arthritis and cognitive impairment which limits her ability to understand safety precautions.

As per the UAS, it appears the patient has significant cognitive impairment. Her mental status is described as confused, poor decision making capacity, memory impairment, easily distracted, episodes of disorganized speech; and also some behavioral problems including wandering, resisting care, verbal outbursts. At this relatively advanced stage of dementia, it is likely that cognitive impairment is a substantial cause of the patient's need for assistance with daily activities for a person with dementia, loss of ability to perform daily activities (IADLs and ADLs) is an expected consequence of the disease. For this patient, the combination of physical (arthritis) and cognitive (dementia) impairments results in significant risk for falls, accidents and injury. 

Based on the review of the available records, it appears that the patient has nighttime ADL needs as identified in the UAS, including toileting, incontinence care and assistance for transfers and ambulation if she attempts to get up at night. These activities typically occur with unpredictable frequency; even more for a person with advanced dementia. The risk of falls and injury to the patient is she tries to get out of bed when the aide is asleep is substantial (e.g. fractures, head injury). The risk of skin injury if she remains in a soiled, wet diaper for several hours is also a significant concern (the UAS nurse made a point of educating the caregivers about frequent change of undergarments).

The ADL needs of the patient, including assistance for transfers, walking, toileting/incontinence care, can occur at any time of the day/night for this patient with incontinence and advanced dementia. Therefore, it is medically necessary for a caregiver to be present and awake throughout the day and night to provide assistance with ADLs when needed. Assistance from informal caregivers as per NYS regulations for personal care services is voluntary. There are family members designated as informal caregivers, but considering the request is to continue CDPAS 2-12 hour split shift, it is reasonable to conclude that the family cannot provide the additional hours of care when the live-in aide is sleeping. 

Consumer Directed Personal Assistance Services 2-12 hours per day, split shift is medically necessary. The health plan did not act reasonably in the best interest of the patient. 

Based on the above, the medical necessity for continuation of Consumer Directed Personal Assistance Services (CDPAS) hours at 7days a week 2-12 hours a day (Split- Shift) is substantiated.  The insurer's denial is reversed.