Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer Directed Personal Assistance Services (CDPAS), 24 hours per day, 7 days a week (split-shift and live-in) for a total of 168 hours a week
The insurer denied coverage for CDPAS, 24 hours per day, 7 days a week (split-shift and live-in) for a total of 168 hours a week.
The denial is overturned.

This case involves a patient seeking authorization for CDPAS, 24 hours per day, 7 days a week (split-shift and live-in) for a total of 168 hours a week. In an assessment form, it was stated that the patient had total dependence on meal preparation, ordinary housework, and shopping. She required maximum assistance for bathing, personal hygiene, and dressing. She required limited assistance with locomotion, transfers to the toilet, and bed mobility. She required maximal assistance with toileting. She required extensive assistance with eating. The recommended total hours were 67 hours per 7 days.

Per the cited references, home health may be indicated when the patient is confined to the home due to illness or injury, and there is a need for the aid of supportive devices such as crutches, canes, wheelchairs, walkers, the use of special transportation, or the assistance of another person to leave their place of residence. Patients who require uninterrupted care by more than 1 personal care aide for more than 16 hours in a calendar day may be appropriate for 24-hour split shift services when a personal care aide is unable to obtain 5 hours daily of uninterrupted sleep during the 8-hour sleep schedule.  

In this case, the patient had a diagnosis of dementia. The patient's daughter reported that the patient needed care at night and on the weekends. The daughter reported that her mother did not sleep most of the night. The coverage would allow the patient to stay in the home setting without having to go to a nursing home. The patient needed assistance in her daily nightly activities. During the day, she needed help with preparing her meals, getting in the shower, getting dressed, diaper changes, and feeding. She also needed assistance with cleaning. At night, she needed assistance with directing and getting into bed, changing her diaper, washing her up, and assisting her when she would get up in the middle of the night. The patient would eat her feces if it were left unattended for too long. It was indicated that the patient had a severe behavioral concerns, urinary incontinence, and insomnia. To improve her quality of life and assist in all activities of daily living, it was recommended that the patient receive full 24-hour home health aide services. The documentation identified that the patient needed assistance with transfers, walking, and toileting. The activities are not limited to 12 hours/per day. It is usual for nighttime toileting needs to increase as a person ages. For patients with dementia, their nighttime behaviors can be unpredictable. It is noted that the patient was frequently awake at night. She required assistance for ambulation and toileting. A caregiver at night that is not asleep is needed for safety supervision and to aid with activities of daily living. Fall prevention should be a priority for the patient. A care provider that is asleep for 5 hours or greater during the night would be unable to provide the supervision needed for appropriate care for the patient with her unpredictable wake schedule at night. The use of personal assistance is crucial for patients with disabilities to allow them to remain in the community as opposed to being placed in institutional settings.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Consumer Directed Personal Assistance Services (CDPAS), 24 hours per day, 7 days a week (split-shift and live-in) for a total of 168 hours a week is overturned. Medical Necessity is substantiated.