Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered Mental Status
Treatment: Consumer Directed Personal Care assistance services, 24 hours per day 7 days per week (Split-shift)
The insurer denied Consumer Directed Personal Care assistance services, 24 hours per day 7 days per week (Split-shift).
The determination is overturned.

The patient has a past medical history of osteoarthritis, osteoporosis, gastroesophageal reflux disease (GERD), depression, hypertension, glaucoma with double vision, retinal artery branch occlusion, constipation, history of transient ischemic attack (TIA), trigeminal neuralgia, history of deep vein thrombosis (DVT) and pulmonary embolism (PE), history of kidney stones, and severe spinal stenosis of the lumbar region who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 63 hours/week.
The patient was hospitalized with the diagnosis of altered mental status and was found to have a large dilated fluid collection around the right kidney. She underwent ureteral stent placement and ultimately interventional radiology (IR) drain placement for perirenal fluid collection. The patient had a follow up appointment with urology and continued to have a post void residual. Her daughter was instructed to use a straight catheter if the patient became uncomfortable. The patient underwent a telephonic assessment tool assessing the patient at total assistance for tasks of meal preparation, ordinary housework, stairs, shopping, locomotion, and toilet use while maximum assistance with tasks of managing finances, managing medication, phone use, transportation, equipment management, bathing, and dressing lower body. With the tasks of personal hygiene, dressing upper body, bed mobility, and eating the patient was assessed at extensive assistance while tasks of walking and transfer toilet were noted to not have occurred. The assessment stated the patient's overall self-sufficiency had significantly changed due to recent hospitalization and she had a decline in health status with difficulty with ambulation, was unable to weight-bear, and was wheelchair-bound.
The patient had an IR catheter exchange with noted a continued large fluid-filled collection in the right perinephric area. The insurer provided a final adverse determination denial notice denying the request to increase CDPAP services stating the request was not medically necessary and the patient did not meet criteria. The denial stated that the daughter had asked for an increase in hours due to the patient having poor vision from severe glaucoma requiring eye drop installation every 12 hours, nephrostomy care and drainage every 6 hours, and a saline solution flush of IR drain every 12 hours. The daughter also stated the patient had a pressure wound located on the sacral area measuring 6 x 6 centimeters(cm) and the patient needed to be turned and positioned every 2-3 hours. In addition, the denial stated the reported change in the patient's medical condition and/or her ability to perform daily personal care task had not impacted her personal care needs. The insurer also noted the care manager had arranged skilled home services for the patient. The denial stated safety supervision was not included as a covered part of total authorized personal care service hours and cognitive prompting was included as part of another task. Lastly, the denial stated the patient did not qualify for requested hours as the patient had no nighttime needs and there is no data that shows the patient needed someone to help turn and position her overnight. The insurer also recommended physical therapy assessment and discussing with the CDPAP aide a schedule that would benefit the patient's needs.
The patient's primary care physician (PCP) provided a letter stating the patient's past medical history and requested an increase in home care service hours for the patient because of her clinical, functional, and mental status deterioration. The letter also noted the patient lived alone and needed additional assistance with toileting, bathing, grooming, dressing, meal preparation, and instrumental activities of daily living (IADLs). The PCP also noted the patient's mental status had worsened and she had become forgetful and depressed. The patient's PCP reported the patient was very unsteady with gait and had a history of falls despite using assistive devices. Documentation reviewed provided a notice that the patient had fallen twice in the past 5 days while being alone for 15 hours every day injuring her elbow and her mouth. The note  also stated the kidney treatment was not successful because the kidney drain and Foley were not being emptied for 15 hours each day.
At issue is the medical necessity of Consumer Directed Personal Care assistance services, 24 hours per day 7 days per week (Split-shift).
The requested services are medically necessary.
The patient has documentation of worsening functional status following hospitalization. She became homebound and had to rely on a wheelchair. The plan's denial notification stated they had been informed patient had a sacral ulcer requiring turning and repositioning every 2-3 hours. The patient had care needs with emptying her nephrostomy drain every 6 hours, providing eye drops every 12 hours, and flushing her drain every 12 hours. The patient had CDPAS services and these tasks were under their scope of practice. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The increase in PCA hours is not solely for safety, supervision or cognitive prompting but to assist the patient with safe completion of activities of daily living (ADLs)/IADLs. The patient's care needs cannot be met with current CDPAP service hours and/or medical supplies and/or adaptive equipment. Due to the patient's assistant needs in the overnight hours a CDPAP aide would not be able to obtain 5 hours of uninterrupted sleep. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.