Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Central Nervous System/Neuromuscular Disorder/Alzheimer's disease

Treatment: Home Health Care/consumer direct personal aide service (CDPAS) 7 days x 12 hours x 2 shifts

The health plan denied the requested consumer direct personal aide service (CDPAS) 7 days x 12 hours x 2 shifts as not medically necessary.

 The health plan's determination is overturned.

The patient is a male with past medical history of Alzheimer's disease, lumbar spinal stenosis, hypertension, urinary incontinence, chronic renal insufficiency, anxiety and osteoarthritis who had a mutual case with his wife for consumer directed personal aide (CDPAS) services who was approved for 24 hours/day, 7 days/week, live -in following Uniform Assessment System (UAS). The patient had multiple falls, most occurring in the overnight hours when he attempted to use the bathroom overnight. There was a request to increase CDPAS services and the patient's primary care physician (PCP) completed form 4359 following an office visit. Notes from insurer noted the daughter reported the patient went to bathroom every 3 hours and refused to use durable medical equipment due to dementia. The patient had a UAS performed via video assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of phone use and transportation. With tasks of managing medication, stairs, and equipment management the patient was assessed at extensive assistance while limited assistance with tasks of bathing, dressing lower body, and toilet use. The patient was assessed at supervision with the task of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and eating while independent with task of bed mobility. The patient had a follow-up visit with his PCP and neurology, noting the patient had ongoing cognitive decline and was referred to physical therapy. The insurer sent a notification that review was extended due to lack of overnight sleep study. Overnight care logs  noted the patient had incontinence care at least every three hours. The patient's PCP provided a letter stating the patient's medical diagnoses, noting the patient gets up in the middle of the night and without assistance he is likely to be injured. The provider recommended to 12-hour shifts for personal care assistant (PCA) services. The patient's PCP sent another letter stating the patient was at times incontinent and needed changing during the night hours to prevent pressure ulcers. The provider also noted the patient had generalized weakness and required repositioning frequently during the night and that his Alzheimer's disease sometimes prevented the patient from sleeping at night.

The health plan's determination of medical necessity is overturned, in whole.

Yes, There is documentation from the patient's PCP and neurologist of worsening physical and cognitive functioning. There is documentation from the patient's PCP of the medical necessity of increasing PCA services to include overnight care. Overnight care logs document the patient has assistance needs with activities of daily living (ADLs) at least every 3 hours which would not allow a PCA 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). The patient's care needs cannot be met with adaptive equipment and medical supplies alone. 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, CDPAS services 7 days x 12 hours x 2 shifts 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 his own home.