Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's disease.
Treatment:  Increase consumer directed personal assistance services (CDPAS) to 7 days per week, 24 hours per day, continuous care by more than 1 person; a total of 168 hours per week.

The insurer denied: Increase consumer directed personal assistance services (CDPAS) to 7 days per week, 24 hours per day, continuous care by more than 1 person; a total of 168 hours per week.  The denial is overturned.

This elderly male patient has medical conditions including advanced Alzheimer's disease and respiratory failure.  He is nonverbal and bedbound.  This is an appeal of denial of an increase in consumer directed personal assistance services (CDPAS) to seven days per week, 24 hours per day, continuous care by more than one person: a total of 168 hours per week.  The health plan approved 91 hours per week, live-in.  Uniform Assessment System evaluation completed earlier this year shows the patient has severely impaired cognition and functional status requires total dependence with all activities of daily living (ADLs).  The patient has a Foley catheter and is incontinent of bowel.  

The appeal states the patient cannot be left alone and the family is unable to care for the patient.  Nighttime logs show diaper changes every four to six hours.  The patient has a history of bed sores, per a statement from his wife, and needs to be turned every two to three hours, per his provider.

The proposed treatment is 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.

This patient has advanced Alzheimer's disease and is bedbound. This is an appeal of denial of increase consumer directed personal assistance services (CDPAS) to seven days per week, 24 hours per day, continuous care by more than one person: a total of 168 hours per week.  The health plan approved 91 hours per week, live-in.  Uniform Assessment System evaluation completed earlier this year shows the patient has severely impaired cognition and requires total dependence with all activities of daily living (ADLs).  He has bowel and bladder incontinence.  Appeal statements support that the patient needs assistance with all activities of daily living.  He needs to be turned every two to three hours.  Nighttime logs support the need for frequent assistance with toileting.  This patient has continuous needs, including frequent turning/repositioning, that will not give the aide five hours daily of uninterrupted sleep during the aide's shift.  The approved consumer directed personal assistance services (CDPAS), live-in, seven days per week is insufficient to meet the patient's needs for assistance with activities of daily living and personal care.  The proposed consumer directed personal assistance services (CDPAS) seven days per week, 24 hours per day, continuous care by more than one person; a total of 168 hours per week is medically necessary.