Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Alzheimer's dementia
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week
The insurer denied Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week.
The denial is partially overturned.

This elderly female patient has conditions including Alzheimer's dementia. The denial of an increase in consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is being appealed. The health plan approved 9.5 hours per day for a total of 66.5 hours per week. Uniform Assessment System evaluation completed 5 months ago showed severely impaired cognition and functional status: total dependence to maximal assistance with all activities of daily living (ADLs). She has bowel and bladder incontinence. There is no significant change compared to Uniform Assessment System evaluation completed 16 months ago. The patient's daughter reports that the patient has deteriorated since being diagnosed with COVID (coronavirus disease). A letter from the patient's physician notes the patient has rapidly deteriorating cognitive and physical health and functioning. She is confined to the bed and wheelchair. She has progressive dementia. She requires assistance multiple times per day with diaper changes. She requires continuous supervision and assistance with activities of daily living (ADLs).

An increase in consumer directed personal assistance program (CDPAP) to 24 hours per day, 7 days per week, live in, is medically necessary for this patient. However, an increase in consumer directed personal assistance program (CDPAP) and:12 hours per day, 7 day(s) per week; 12 hours per day, 7 day(s) per week (split shift) - for a total of 168 hours per week is not 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. This patient has chronic conditions that include Alzheimer's dementia. Denial of an increase in consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week for 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is being appealed. The health plan approved 9.5 hours per day for a total of 66.5 hours per week. The health plan denied the additional hours based on the Uniform Assessment System (UAS) evaluation and noted that hours could be adjusted to meet the patient's needs. Uniform Assessment System evaluation completed 5 months ago, shows the patient requires maximal assistance to total dependence with all activities of daily living (ADLs). She is incontinent of bowel and bladder. Compared to Uniform Assessment System (UAS) evaluation completed 16 months ago, the patient required maximal assistance to total dependence with all activities of daily living. The appeal statements note that the patient's cognitive and physical functioning are deteriorating. She is confined to the bed and wheelchair. The information provided shows that this patient has significant limitations in functioning. The approved consumer directed personal assistance program (CDPAP) at 66.5 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The information does not support that the patient has continuous needs that will not allow an aide 5 hours of sleep. The proposed consumer directed personal assistance program (CDPAP) 12 hours per day - 7 days per week and 12 hours per day - 7 days per week, split shift, is not medically necessary. However, an increase consumer directed personal assistance program to 24 hours per day, 7 days per week, live in, is medically necessary for this patient.