Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia, macular degeneration, osteoporosis, diabetes, arthritis, and heart disease
Treatment: Increase in Consumer Directed Personal Assistance Services (CDPAS) to 12 hours (split shift) 7 days/week
The insurer denied an increase in CDPAS to 12 hours (split shift) 7 days/week.
The denial is overturned.

This elderly female has medical conditions that include dementia, macular degeneration, osteoporosis, diabetes, arthritis, and heart disease. Denial of an increase in consumer directed personal assistance services (CDPAS) to 12 hours (split shift) 7 days/week is being appealed. The health plan approved 84 hours/week.

Uniform Assessment System (UAS) evaluation completed 7 months ago shows severely impaired cognition and functional status requiring extensive assistance to total dependence with all activities of daily living (ADLs), except suspension with bed mobility and limited assistance with eating. The patient has frequent bladder incontinence.

An appeal statement from New York State notes the patient has declined over the past year. She has been in inpatient rehab twice in the last nine months after hospitalization for deep vein thrombosis (DVT) and a hip fracture after a fall. The most recent falls occurred 6 months ago and 3 months ago. She needs assistance with all ADLs, including overnight assistance with toileting.

A letter from the patient's child notes the patient was recently discharged from rehab and needs continuous assistance. Overnight logs support the patient getting assistance with toileting every two to four hours.

A letter from the nurse practitioner notes the patient ambulates using a wheelchair and is a high fall risk. She requires constant assistance with transferring and toileting.

A letter from a provider notes the patient has several chronic conditions and is prone to falls. She needs assistance with all ADLs.

The requested health service is medically necessary. 

Personal care service (PCS) 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 PCS 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 recent hospitalization and inpatient rehab for DVT and hip fracture. Denial of an increase in CDPAS to 12 hours (split shift) 7 days/week is being appealed. The health plan approved 84 hours/week. UAS evaluation completed 7 months ago showed the patient requires extensive assistance to total dependence with all ADLs, except supervision with bed mobility and limited assistance with eating. The patient has frequent bladder incontinence. Appeal statements support that the patient needs assistance with all ADLs, including frequent nighttime assistance with toileting. This is supported by nighttime logs assistance with toileting every two to four hours. The information provided supports that this patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved CDPAS 84 hours/week is insufficient to meet the patient's continuous needs. The proposed increase to 12 hours (split shift) 7 days/week is medically necessary.