Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple sclerosis, hypertension, hypothyroidism, and diabetes
Treatment: Consumer Directed Personal Assistant (CDPA) 196 hours/week (24-hour split shift, plus additional 4 hours/day for a second aide to assist with lifting and transfers)
The insurer denied the CDPA 196 hours/week (24-hour split shift, plus additional 4 hours/day for a second aide to assist with lifting and transfers).
The denial is overturned.

This elderly male has conditions including multiple sclerosis, hypertension, hypothyroidism, and diabetes. The denial of consumer directed personal assistant (CDPA) 196 hours/week (24-hour split shift, plus additional 4 hours/day for a second aide to assist with lifting and transfers) is being appealed. The health plan approved 65 hours/week.

Uniform Assessment System (UAS) evaluation completed last month shows independent cognition and functional status: total dependence with housework, transportation, lower body dressing, and toileting; maximal assistance with meal preparation, bathing, upper body dressing and bed mobility; extensive assistance with managing medications, shopping, and personal hygiene; and independent with eating. Hoyer lift will not fit into the house. The patient has a Foley catheter. He is incontinent of bowel.

A letter from the patient's daughter-in-law reports the patient requires two people to get out of a chair and into the stair lift. He has Clostridium difficile (C diff) with bowel incontinence and has had to sit in feces overnight. He can only shower once a week. He needs aids to get him to doctor's appointments. The current hours have required choosing between appointments, showering, and toileting. The patient lives with his wife who can provide limited support.

An additional letter has been provided reporting that the patient needs assistance with transfers and bed mobility. He needs assistance with doctor's visits and toileting. He has been found lying in feces due to lack of assistance.

There are case notes and night logs showing the need for frequent assistance. The patient receives assistance to include assistance with toileting and repositioning every one to two hours.

The proposed treatment is medically necessary.

Personal care service (PCS) 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 PCS 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 multiple chronic conditions, including multiple sclerosis. The denial of CDPA 196 hours/week (24-hour split shift, plus additional 4 hours/day for a second aide to assist with lifting and transfers) is being appealed. The health plan approved 65 hours/week. UAS evaluation completed last month shows the patient requires extensive assistance to total dependence with all activities of daily living (ADLs), except eating. He is incontinent of bowel. The appeal statements and night logs support the patient is dependent with all ADLs and requires frequent assistance with toileting, transfers, and repositioning. He requires two-person assist with transfer to chair. A Hoyer lift cannot fit into the home. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved CDPA 65 hours/week is inadequate to meet this patient's needs. The proposed CDPA 196 hours/week (24-hour split shift, plus additional 4 hours/day for a second aide to assist with lifting and transfers) is medically necessary.