Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizophrenia, bipolar disorder, depression, anxiety, and seizures
Treatment: Increase Consumer Directed Personal Assistance (CDPAS) Services to 24 Hours a Day, 7 Days a Week (Split Shift) for a Total of 168 Hours
The insurer denied: Increase Consumer Directed Personal Assistance (CDPAS) Services to 24 Hours a Day, 7 Days a Week (Split Shift) for a Total of 168 Hours.
The denial is upheld.

This adult male has conditions including schizophrenia, bipolar disorder, depression, anxiety, and seizures. He also suffers from hallucinations and delusions. He was diagnosed with COVID (coronavirus disease) last summer. He was admitted to the hospital a couple of months later with a urinary tract infection and pulmonary complications and again the following month with hypoxia, obstructive sleep apnea and pulmonary complications. The patient was admitted to inpatient psychiatry the next month. The patient is appealing denial of an increase in consumer directed personal assistance (CDPAS) services to 24 hours a day, seven days a week (split shift), for a total of 168 hours. The health plan approved 91 hours per week.

Uniform Assessment System (UAS) evaluation completed recently shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, shopping, bathing, waking, and toilet use; and maximal assistance with when use, personal hygiene, dressing, toilet transfer, bed mobility, and eating. 

The patient is mostly bedbound. He is unable to hold anything due to hand tremors. He is incontinent of bowel and bladder. He has had three falls in the past 90 days. A letter from his provider states that the patient requires constant care and supervision. The patient is impaired due to medical and psychiatric conditions. He needs assistance with activities of daily living, including unpredictable nighttime incontinence. His mother and father are no longer able to provide care. The patient is prone to psychiatric decompensation.

The proposed treatment is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient primarily has multiple chronic psychiatric conditions and is bedbound. He has had several recent inpatient admissions. He is appealing denial of an increase in consumer directed personal assistance (CDPAS) services to 24 hours a day, seven days a week (split shift), for a total of 168 hours. The health plan approved 91 hours per week. Uniform Assessment System (UAS) evaluation completed recently shows the patient requires maximal assistance to total dependence with activities of daily living. He is incontinent of bowel and bladder. An appeal statement from the patient's provider notes the patient requires constant care and supervision as he is prone to psychiatric decompensation. Also, the appeal notes the patient has unpredictable nighttime incontinence. The information provided does not support that the patient has continuous needs. Consumer directed personal assistance services are not indicated for supervision or when no tasks are being performed. The approved consumer directed personal assistance services 91 hours per week is sufficient to meet the patient's needs for assistance with activities of daily living and personal care. The proposed increase in services to 24 hours a day, seven days a week (split shift), for a total of 168 hours is not medically necessary.