Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia. 
Treatment: Increase consumer and self-directed personal assistance services to 24 hours a day 7 days a week (split shift) for 168 hours per week. 

The insurer denied: Increase in consumer & self-directed personal assistance services to 24 hours a day 7 days a week (split shift) for 168 hours per week. 

The denial is upheld. 

The patient is a female with medical history notable for dementia, urinary incontinence, gait disorder, and chronic bronchitis. The patient is currently approved for 63 hours per week of consumer and self-directed personal assistance services. The patient and her care team requested an increase to 24 hours per day (split-shift), 7 days per week (168 hours per week). This request was denied by the health plan, and this denial is the subject under review. 

A letter of medical necessity for this appeal was provided by the patient's physician. The letter states that the patient is on multiple medications including diuretics, and needs to toilet at night. She cannot do this without assistance, and cannot stay in wet diapers due to the risk of skin breakdown. The patient has no informal care assistance. She "requires continuous assistance daily." 

A letter of support for this appeal was provided by the patient's daughter. The letter states that the patient now requires hands on assistance for all activities. She fell while attempting to ambulate recently and suffered a laceration on her head. She has dementia and does not remember to eat or take medications without assistance. She requires help with bed transfers and toileting. She attempts to get out of bed by herself at night and refuses to wear diapers (due to her dementia). 

A Uniform Assessment System (UAS) was completed and was available for review. The patient's cognition was moderately impaired; she was alert and oriented times two only. She is able to make simple needs known but could not state her goals of care. From a functional standpoint, the patient requires total dependence for housework and shopping. She requires maximal assistance for meal preparation, managing finances, managing medications, phone use, and stairs. For her activities of daily living (ADLs), she requires maximal assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene and dressing upper body. She is frequently incontinent of urine and occasionally incontinent of stool. She uses pull ups and her Consumer Directed Personal Assistance Services (CDPAS) assists her with changes. An Hours Evaluation for Paraprofessional Support (HELPS) assessment associated with the UAS recommended 58 hours per week to address her personal care needs. 

The health plan's determination is upheld. 

The requested health service/treatment of increase your consumer and self-directed personal assistance services to 24 hours a day 7 days a week (split shift) for 168 hours per week has not been demonstrated to be medically necessary for this patient. 
The patient has a number of behaviors that raise safety concerns related to her dementia. There is documentation in multiple places that she has nighttime wandering. She attempts to use the bathroom every hour overnight in part due to wandering behavior. She does not comply with using diapers. Her physician recommends constant supervision. 
Safety supervision and monitoring separate from personal care tasks is not a level 2 personal care function. The patient has personal care needs, and is granted sufficient CDPAS hours to cover them. The hours are consumer directed and could be used strategically throughout the day to address her needs. Beyond that, she has safety concerns related to her dementia that do not meet criteria for a personal care aide. These should be addressed with her physician regarding options for the best location of care for the patient.