Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer Directed Personal Aide Service (CDPAS) 7 days x 12 hours
The health plan denied Consumer Directed Personal Aide Service (CDPAS) 7 days x 12 hours.
The determination is overturned. 

The patient is a male with a medical history notable for dementia, difficulty walking, and incontinence. He is approved for 44 hours per week of consumer directed personal aide service (CDPAS). The patient and his care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and the request was denied by the health plan.
The request for additional hours was completed by the treating physician. The documentation states that the patient requires "around the clock care due to incontinence, assistance with transfers, ambulation, toileting. The patient has tremors affecting his grasp and has not improved despite physical therapy (PT)." The physician also provided a letter of support for this appeal stating that the patient has had frequent falls recently. He requires assistance with ambulation, transfers, and toileting, he is incontinent of urine and requires assistance with changing incontinence care products. The patient also has episodes of dizziness and bradycardia. The physician states that the patient requires help in the home throughout the day to assist him with all functional needs.
Daily care logs for the patient were also provided for review. The logs demonstrate that the patient requires assistance with personal care tasks for essentially every hour of the day. He requires help with toileting, changing incontinence care products, ambulation, meal preparation, and transportation.
A Uniform Assessment System (UAS) was completed via teleconference. The patient lives with his daughter and son-in-law (who serves as his consumer directed aide). The patient was alert and oriented to person and place only with moderately impaired cognition. For his instrumental activities of daily living (IADL's), he requires total dependence for meal preparation, housework, finances, medications, and shopping. He requires maximal assistance for stairs and transportation. For his activities of daily living (ADL's), he requires extensive assistance for bathing, dressing lower body, and toilet use. He requires limited assistance for walking and locomotion. He is otherwise independent for ADL's. He uses a walker to ambulate and requires hands-on assistance for safety and he requires one person for all transfers. The patient is frequently incontinent of urine and infrequently incontinent of stool, using 8-10 pull-ups per day and requiring doubling up of the pull-ups to prevent overflow; he requires assistance with all changes. Compared to a prior UAS, he showed a decline in functional status.
At issue is the medical necessity of Consumer Directed Personal Aide Service (CDPAS) 7 days x 12 hours.

The requested health service of Consumer Directed Personal Aide Service (CDPAS) 7 days x 12 hours (hrs) is medically necessary for this patient.
The documentation provided demonstrates that the patient requires hands-on assistance for essentially all personal care tasks. He is incontinent and requires assistance with toileting and changing pull-ups. The daily care logs demonstrate that these tasks are unscheduled and occur continuously throughout the day. The UAS task tool is a reasonable starting guideline but should not be the final determining factor in allocating hours to a patient. He has documented evidence of unmet personal care needs which require additional hours. Therefore, the requested increase to 12 hours per day x 7 days is medically reasonable and necessary for the patient.