Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gait instability, Falls.
Treatment: Home Health Services.
The insurer denied consumer and self directed personal assistance services 24 hours a day, 7 days a week (live-in or split-shift).
The determination is overturned.


The patient has a past medical history of hypertension, hyperlipidemia, atrial fibrillation, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease (COPD), urinary incontinence, bowel incontinence, uterovaginal prolapse, recurrent urinary tract infections (UTI), fungal skin infections, depression, insomnia, osteoporosis, recurrent falls, gait instability, and dementia who had been assigned Consumer Directed Personal Assistance Services (CDPAS) services 10 hours/day, 7 days a week to total 70 hours/week following a hospitalization and rehabilitation stay after a fall with multiple rib fractures, congestive heart failure, and pneumonia. There was a request to increase CDPAS services to 24 hours/day, 7 days/week and the patient had an assessment tool performed telephonically. The patient was assessed at total assistance with tasks of managing finances and maximal assistance with tasks of meal preparation, ordinary housework, shopping, transportation, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of managing medication, phone use, stairs, equipment management, dressing upper body, walking, locomotion, transfer toilet, and toilet use and limited assistance with tasks of personal hygiene and bed mobility. With the task of eating the patient was assessed at supervision only. Notes from the nurse performing the assessment stated the patient lived alone in a three bedroom apartment, tries to walk but forgets to use her walker, fell when CDPAS not present, and has a recurrent UTI and is not able to clean herself properly after toileting. In addition, the assessment notes documented that the patient only had her daughter as informal helper and the daughter needed to help her husband who had his own medical issues.

The insurer sent a final adverse determination notice denying the requested increase for CDPAS hours, stating the service was not medically necessary and the patient did not meet criteria. The denial letter further stated the patient had equipment and supplies that can meet her needs and can have physical therapy (PT)/occupational therapy (OT) services to improve functional status. In addition, the denial notice stated increased aide hours does not prevent falls or injuries and the aide cannot always watch the patient and increased aide service hours are not provided for companion care or safety supervision. The patient's primary care physician (PCP) provided a letter documenting the medical necessity of 24 hour home care, reiterating the patient's medical diagnoses and the needed assistance with bathing, toileting, dressing, medication administration, cooking, housecleaning, and transportation. The letter further stated the patient has had several falls resulting in multiple fractures and hospitalizations. In addition, the letter stated the patient requires split-shift care 24 hours/day as she requires total assistance with transfers, ambulating, toileting, incontinence cares, bed mobility, personal hygiene, eating, and upper/lower body dressing. The patient had an office visit with the PCP documenting her medical diagnoses. Overnight logs were recorded noting assistance needs with walking, locomotion, personal hygiene, bed mobility, transfer toilet, and toilet use every 1-5 hours. The overnight logs also documented maximal assistance with all tasks. A home physical therapy (PT) note documented that the patient has dyspnea on exertion and the bed is too high and makes transfers unsafe without supervision (daughter looking for smaller box spring). The patient's healthcare advocate provided a letter requesting an expedited appeal of denial decision also stating the plan did not create a safe person-centered care plan addressing safety and maintenance of the patient's day and overnight needs, improperly tasked for hours when unscheduled day and overnight needs exist, did not ensure safety and supervision was provided with functional tasks, and implied that technology and supplies can be safely used but patient has recurrent UTI with delirium and often forgets to use her walker when not prompted. The advocate letter further documented the patient's history of falls with details occurring. At issue is the medical necessity of consumer and self directed personal assistance services 24 hours a day, 7 days a week (live-in or split-shift).

The requested services are medically necessary.

The patient has a past medical history of multiple chronic medical problems that limit her functional status. In addition, the patient has urinary incontinence, bowel incontinence and is unable to perform incontinence care on her own. The patient also has dementia and often forgets to use her walker without prompting, which has lead to multiple falls with injury over the last two years. The patient has overnight needs at least every 1-3 hours. The patient requires assistance with all activities of daily living (ADLs)/instrumental activities of daily living (IADLs). The plan did not document a plan that could meet the patient's unscheduled and unpredictable care needs during day and nighttime. The Uniform Assessment System (UAS) was not properly utilized in assessing CDPAS hours as the patient has unscheduled and unpredictable care needs. An increase in CDPAS hours is not solely for companionship, safety or supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's PCP/attending physician documented the medical necessity of 24 hour, split-shift CDPAS services in a letter. Taking into consideration the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines 24 hour, split-shift CDPAS services are medically necessary for this patient. PCA (personal care assistant)/CDPAS 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 her own home.