Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day (live-in), 7 days a week for a total of 91 hours per week.
The insurer denied Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day (live-in), 7 days a week for a total of 91 hours. per week.
The determination is overturned.

This is a female patient with a history of dementia, chronic kidney disease stage 3, hyperparathyroidism, hearing loss, history of colon cancer, dyspnea, osteopenia, frequent falls, and urinary and bowel incontinence. The patient lives alone in a 3-bedroom private home. The patient was previously approved for 49.5 hours per week of Consumer Directed Personal Assistance Services (CDPAS). The patient and her care team are requesting CDPAS 24 hours a day (live-in), 7 days a week for a total of 91 hours per week.
An in-person Uniform Assessment System (UAS) was completed. The patient was assessed for total dependence on ordinary housework, managing finances, and shopping; maximal assistance for meal preparation, managing medications, phone use, bathing, dressing the upper body, and dressing the lower body; extensive assistance with stairs, transportation, personal hygiene, and toilet use; limited assistance for walking, locomotion, transfer toilet, bed mobility, and eating. The UAS states that the patient needs assistance to change incontinence pads. A tasking tool was used to determine that she requires 47 hours of aide service per week.
The patient's primary care physician provided a letter of support. Her primary care physician (or provider) (PCP) states that the patient has been experiencing worsening dementia unsafe behaviors. She has been getting up at night and attempting to leave the house. She had a fall due to being anxious and agitated. The patient's PCP states she needs 24-hour assistance to provide safe care, reduce the risk of falls and injury, and help to redirect her at night.
At issue is the medical necessity of consumer-directed personal assistance services (CDPAS) 24 hours (hrs.) a day (live-in) 7 days a week for a total of 91 hrs.

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 24 hours a day (live-in) 7 days a week for a total of 91 hours is medically necessary.
There is documentation in the UAS of the patient requiring extensive assistance with toilet use and needing assistance with changing incontinence pads. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time, and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The insurer should not have utilized a tasking tool to calculate hours given the patient's assistance with unscheduled and unpredictable care needs. There is documentation from the patient's PCP of the medical necessity of increased CDPAS services. The patient does not have informal support for the entire time outside of the previously assigned PCA hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with ADLs.