Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia. 
Treatment: Consumer Directed Personal Assistance Services, 24 Hours Per Day (split shift). 

The insurer denied the Consumer Directed Personal Assistance Services, 24 Hours Per Day (split shift). 
The denial is overturned. 

The patient is a female. Her conditions include Alzheimer's dementia. Denial of Consumer Directed Personal Assistance Services (CDPAS), 24 Hours per day, split shift, is being appealed. The health plan approved CDPAS (Consumer Directed Personal Assistance Services) live-in. 

The patient's Uniform Assessment System (UAS) evaluation completed shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, phone use, and shopping; maximal assistance with bathing, personal hygiene, dressing, walking, toilet use, and locomotion; and extensive assistance with stairs, toilet transfer, bed mobility, and eating. She is incontinent of bowel and bladder. UAS (Uniform Assessment System) evaluation performed most recently, shows the patient is bedbound and deterioration to total dependence with bathing, personally hygiene, dressing, walking, toilet use, bed mobility, and eating. 

Per an appeal letter, the patient's child notes the patient is nonverbal, bedbound and fully incontinent of bowel and bladder. Notes the patient's cognitive and physical health have declined and she needs help with every task. Notes she has nighttime needs. She is incontinent and unable to change. It is recommended that she be turned/repositioned every 2 hours. 

An appeal letter from the patient's provider notes the patient's condition has progressively worsened and she is bedbound and requires 24/7 assistance. 

Yes, the requested Consumer Directed Personal Assistance Services, 24 Hours Per Day (split shift) 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. Denial of CDPAS (Consumer Directed Personal Assistance Services), 24 Hours per day, split shift, is being appealed. The health plan approved CDPAS (Consumer Directed Personal Assistance Services) live-in. 

This patient has progressive Alzheimer's dementia. UAS (Uniform Assessment System) evaluation completed most recently shows the patient it totally dependent with all ADLs (activities of daily living) and personal care. This shows progression from UAS (Uniform Assessment System) evaluation completed previously. She is incontinent of bowel and bladder. The appeal statements note the patient's condition has progressed to now being bedbound. She is totally dependent and requires turning/repositioning every 2 hours. This patient has significant limitations to cognitive and physical functioning. The frequency of services needed cannot be met with the approved CDPAS (Consumer Directed Personal Assistance Services) 24 hours, live-in. The requested CDPAS (Consumer Directed Personal Assistance Services) 24 hours, split shift is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.