Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia; Community acquired pneumonia.

Treatment: Consumer Directed Personal Care Services (CDPAS), 24 hours(s) per Day (Live in).

The insurer is denied coverage for Consumer Directed Personal Care Services (CDPAS), 24 hours(s) per Day (Live in). 
The denial is overturned.

The patient is a female with a history of hypertension, chronic atrial fibrillation, coronary artery disease, congestive heart failure, diabetes mellitus, tuberculosis and congenital absence of one lung. She was admitted to the hospital for community acquired pneumonia.  Cardiology notes indicated that 24/7 care was recommended. The patient required increased hours at home with assistance for activities of daily living (ADLs). Her mental status had deteriorated and her dementia had worsened with hallucinations. Her family was unable to give the required care. The patient was discharged to SAR. The patient had previously had care 30 hours/wk. 

A Uniform Assessment System (UAS) completed noted that the patient was alert and oriented x 2, able to recall 0/3 words and unable to dial 911. The patient had total dependence on meal preparation and housework, required maximal assistance with managing medications, extensive assistance with bathing, toileting and dressing, limited assistance with personal hygiene and dressing upper body, and with walking/locomotion. A steady gait was observed.

The insurer has denied coverage for Consumer Directed Personal Care Services (CDPAS) 24 hours(s) per Day (Live in) as not medically necessary. In their Final Adverse Determination letter they note that this is a female with diabetes, atrial fibrillation, depression, congestive heart failure and cognitive impairment. She is currently in a nursing home for rehabilitation after a hospitalization for pneumonia. Previously she lived alone. A request for increase in PCA services was made. The patient was assessed in the nursing home. Her NFLOC score increased from 17 to 18, and her gait velocity improved from 0.15 meters/second to 0.29 meters/second. She was stabilized, following directions and able to ambulate 80 feet with rolling walker. Her oxygen saturation was 92% on room air. 

Resident Care Summary notes need for extensive assistance or assistance x1 for all functions. She ambulates 40' twice a day with extensive assistance. She needs assistance x1 for transfers. This reviewer does not agree with the plan's assessment of the need for more care. This is due to a difference in interpretation of the information. 

The patient is unable to use a phone to call 911. She requires extensive assistance in multiple functions, and needs assistance for transfers. She has documented dementia with psychiatric overtones. There are safety issues related to all functions, personal ADLs as well as transfers and ambulation. She is at increased risk of falls and her ability to deal with such a problem is impaired. These deficits are persistent and justify live-in care. The health plan did not act reasonably. 

Based on the above, the medical necessity for Consumer Directed Personal Care Services (CDPAS), 24 hours(s) per Day (Live in) is substantiated. The insurer's denial is overturned.