Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CVA (cerebral vascular accident). 
Treatment: Consumer Directed Personal Assistance Services, 24 hours per day, split shift services, seven days per week. 

The insurer denied the Consumer Directed Personal Assistance Services, 24 hours per day, split shift services, seven days per week. 

The denial is overturned. 

This female patient has a history of cerebral vascular accident (CVA) with residual right-sided weakness and impaired cognition.  She is appealing denial of Consumer Directed Personal Assistance Services, 24 hours per day, split shift services, seven days per week.  The Plan approved Consumer Directed Personal Assistance Services 12 hours per day, seven days per week, total of 84 hours per week.  The patient's daughter has reported that the patient has nighttime anxiety and needs help with activities of daily living (ADLs) as already accounted for in the Uniform Assessment System (UAS) evaluation.  Uniform Assessment System evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, shopping, bathing, locomotion, lower body dressing, toileting, and bed mobility; maximal assistance with managing medications, personal hygiene, upper body dressing, and eating; and extensive assistance with managing finances, phone use.  She is wheelchair bound.  She is frequently incontinent of bowel and bladder. 

An appeal statement notes the patient's condition has deteriorated in recent months.  The appeal notes the patient requires assistance with activities of daily living as already accounted for in the Uniform Assessment System evaluation.  It states the patient has frequent incontinence during the day and night and due to improper hygiene and has developed pressure ulcers.  It notes repositioning is required every two hours.  Personal care logs provided are written in another language. 

Yes, the proposed treatment is 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 has multiple chronic conditions including a history of stroke with residual right-sided weakness.  The patient is wheelchair bound.  She is appealing denial of Consumer Directed Personal Assistance Services, 24 hours per day, split shift services, seven days per week.  The Plan approved Consumer Directed Personal Assistance Services 12 hours per day, seven days per week, total of 84 hours per week.  Uniform Assessment System evaluation completed shows that the patient requires assistance with all activities of daily living and personal care needs.  She is incontinent of bowel and bladder.  The appeal statement notes the patient's condition has deteriorated in recent months.  The patient has pressure ulcers due to poor hygiene and need for repositioning.  It notes the patient requires repositioning every two hours.  This patient has continuous needs that cannot be met with the approved consumer directed personal assistance services (CDPAS) 84 hours per week.  The proposed consumer directed personal assistance services (CDPAS) 24 hours per day split shift services, seven days per week, is medically necessary to meet the patient's needs for assistance with activities of daily living and personal care. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.