Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, arthritis, glaucoma, and gastroesophageal reflux disease (GERD)
Treatment: consumer directed personal assistance program (CDPAP) 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week
The insurer denied coverage for consumer directed personal assistance program (CDPAP) 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week.
The denial is overturned.
 
This is an elderly patient who lives alone. The patient has been diagnosed with dementia, arthritis, glaucoma, and gastroesophageal reflux disease (GERD). The Uniform Assessment System (UAS) reviewed is the most recent. Notes indicate dementia but oriented X2 (person and place), unable to complete tasks, procedural memory problems. Noted total dependence or maximal assistance for all instrumental activities of daily living (IADLs) including phone use. She needed maximal assistance for bathing, personal hygiene, dressing upper/lower body, toilet transfer and toilet use. Needs extensive assistance for eating. The patient is incontinent of bowel and bladder but can toilet with assistance. It is noted, the patient's daughter and granddaughter are supportive and involved in her care. The patient has a glucometer, shower chair, grab bar, walker, and incontinent supplies. The daughter notes that the patient is frequently up at night at times to toilet, wandering. The request is for consumer directed personal assistance program (CDPAP) 12 hours per day - seven days per week; 12 hours per day - seven days per week (split shift) - for a total of 168 hours per week, which is under review.

The records provided for review noted that the patient is wandering multiple times during the night, toileting, eating and at one point was forgetting to turn off the stove. The patient's care needs are at a level or unpredictable so as to require around the clock home care services. It is reasonable to assume that the dementia noted in the prior UAS which showed her oriented X2 (person and place) and more recently oriented X2 (person and place) has continued to progress.  

Consumer directed personal assistance program (CDPAP) 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week is considered medically necessary for this patient.

"Activities of daily living (ADL) is used as an indicator of a person's functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life. Measurement of an individual's ADL (Activities of daily living) is important as these are predictors of admission to nursing homes, need for alternative living arrangements, hospitalization, and use of paid home care." (Edemekong, P. F. et al.).

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for consumer directed personal assistance program (CDPAP) 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week is substantiated.