Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Consumer Directed Personal Assistance Service (CDPAS), 144 hours a week. 
The insurer denied coverage for Consumer Directed Personal Assistance Service (CDPAS), 144 hours a week. 
The denial is overturned. 

This case involves a patient who lives alone and has their family as their support system, with no informal helper. The patient is noted to have a diagnosis of dementia, congestive heart failure, obesity, chronic obstructive pulmonary disease (COPD), hyperlipidemia, hypothyroidism, insomnia, moderate persistent asthma, osteoporosis, conductive hearing loss, cortical age-related cataract, depression, and wandering. Current medications include Advair Diskus, Anora, aspirin, benzonatate, Bystolic, folic acid, gabapentin, isosorbide, loratadine, magnesium, memantine hydrochloride, naproxen, Olmesartan, pantoprazole, rosuvastatin, Synthroid, trazadone, and vitamin D3. It was noted that the patient was receiving 24/7 split shift home health aide (HHA) services. 

The patient is noted to have moderately impaired cognition, memory difficulties, nocturia, bowel and bladder incontinence, minimal hearing difficulty, moderate vision difficulty, has a history of wandering, and is unable to call for assistance during an emergency. It was noted that the patient is unable to make needs known and requires supervision at all times. The patient is frequently incontinent of bladder, and occasionally incontinent of bowel. It was stated that the patient has difficulty chewing and swallowing. The patient has a wheelchair, cane, bedside commode, shower chair, and grab bar, and ambulates indoors with a rolling walker and weightbearing assistance and ambulates outdoors with a wheelchair. 

According to the Hours Evaluation for Paraprofessional Support (HELPS) assessment, 44.5 hours per week of formal support is needed to meet the patient's needs. It was stated that the patient requires assistance with meal preparation, eating, housekeeping, laundry, shopping, dressing, bathing, transferring, toileting, and personal hygiene. 

Based on the documentation available for review, the health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The Consumer Directed Personal Assistance Service (CDPAS), 144 hours a week is considered medically necessary for this patient. The records available for review indicate that the patient has memory difficulties, nocturia, is at risk for frequent falls, and has a history of wandering outside at night when left alone. The patient is unable to call 911 in an emergency, and cannot make their needs known. The increase of Consumer Directed Personal Assistance Service (CDPAS) can allow for increased safety and comfort of the patient in their home and help prevent caregiver fatigue. As such, the denial of Consumer Directed Personal Assistance Service (CDPAS), 144 hours a week, is overturned. 

Based on the above, the insurer's denial must be reversed. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Consumer Directed Personal Assistance Service (CDPAS), 144 hours a week services is substantiated.