Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Consumer Directed Personal Assistance Services (CDPAS) to 24 Hours per Day (Live-in) for 2 Days per Week (Saturday and Sunday)
The insurer denied Increase Consumer Directed Personal Assistance Services (CDPAS) to 24 Hours per Day (Live-in) for 2 Days per Week (Saturday and Sunday).
The denial is overturned.

This elderly male patient has medical conditions that include dementia and stroke with residual blindness. The denial of an increase consumer directed personal assistance services (CDPAS) to 24 hours per day (live-in) for 2 days per week (Saturday and Sunday) is being appealed. The health plan approved CDPAS 12 hour per week (Saturday and Sunday). 
Uniform Assessment System (UAS) evaluation completed 3 months ago shows moderately impaired cognition and the patient requires assistance with all activities of daily living. The patient has bowel and bladder incontinence. Prior Uniform Assessment System evaluation performed 5 months ago shows the patient as independent with toilet use and bed mobility. He had one fall in the last 90 days. An appeal statement notes the patient needs assistance with all activities of daily living including nighttime toileting and diaper changes. He needs assistance with evening feeding. A letter from the Provider notes the patient's condition has declined since recent a hospitalization. He has weakness, loss of sight, dementia and is incontinent of urine. He has lost his eyesight and is confused when walking. He cannot use the commode without assistance. He currently has a private aide assisting with diapering and toileting. The aide gets up 2-3 times per night.

The requested increase in increase consumer directed personal assistance services (CDPAS) to 24 hours per day (live-in) for 2 days per week (Saturday and Sunday) is medically necessary. 

Consumer directed personal assistance services (CDPAS) is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, walking, transfers, turning/positioning, or feeding. This patient has dementia and has had a recent stroke with residual blindness. The denial of an increase consumer directed personal assistance services (CDPAS) to 24 hours per day (live-in) for 2 days per week (Saturday and Sunday) is being appealed. The health plan approved CDPAS (consumer directed personal assistance services) 12 hour per week (Saturday and Sunday). The plan states splitting these hours is sufficient to meet the member's needs for assistance with ADLs (activities of daily living). Uniform Assessment System (UAS) evaluation completed 3 months ago shows the patient requires assistance with all activities of daily living. The prior Uniform Assessment System evaluation performed 5 months ago shows the patient was independent with toilet use and bed mobility. He is incontinent of bowel and bladder. Appeal statements indicate that his condition has declined since a recent hospitalization and supports that he needs assistance with all activities of daily living. He needs frequent assistance with toileting. The information provided shows that this patient has significant limitations in functioning that have progressed since his stroke. The approved CDPAS (consumer directed personal assistance services) 12 hour per week (Saturday and Sunday) is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase CDPAS (consumer directed personal assistance services) to 24 hours per day (live-in) for 2 days per week (Saturday and Sunday) is medically necessary.