Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia and Spinal Disease. 
Treatment: Increase in Consumer Directed Personal Assistance Services 24 Hours A Day 7 Days A Week (split shift). 

The insurer denied the Increase in Consumer Directed Personal Assistance Services 24 Hours A Day 7 Days A Week (split shift). 
The denial is overturned. 

The patient is a female. Her conditions include dementia and spinal disease. She lives with her daughter. Denial of increase in consumer directed personal assistance services (CDPAS) 24 hours a day 7 days a week, split shift, is being appealed. The health plan approved CDPAS (consumer directed personal assistance services) 70 hours per week. 

Uniform Assessment Systems (UAS) evaluation completed shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, lower body dressing, and locomotion; maximal assistance with bathing, personal hygiene, upper body dressing, toilet transfer; and extensive assistance with bed mobility and eating. The patient is bedbound and incontinent of bowel and bladder. 

An appeal statement notes the patient has chronic medical conditions, is bed bound and needs assistance with both day and nighttime ADLs (activities of daily living). The patient's daughter is unable to provide informal support overnight. A letter from the patient's provider notes the patient is home and bed bound. She has dementia and advanced spinal disease resulting in weakness and spasticity of extremities. She is dependent for all ADLs (activities of daily living). She has deteriorating physical and mental status. A letter from another provider notes the patient is bedbound and has poor bed mobility requiring assistance with turning/positioning in the bed. 

Yes, the Increase in Consumer Directed Personal Assistance Services to 24 Hours A Day 7 Days A Week (split shift) is medically necessary. 

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

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. Denial of increase in CDPAS (consumer directed personal assistance services) 24 hours a day 7 days a week, split shift, is being appealed. The health plan approved CDPAS (consumer directed personal assistance services) 70 hours per week. 

This patient has multiple chronic medical conditions, including dementia and spinal disease. She is bedbound. UAS (Uniform Assessment System) evaluation completed shows the patient requires extensive to total assistance with all ADLs (activities of daily living). She has bowel and bladder incontinence. Appeal statements note the patient has deteriorating mental and physical functioning. She is dependent with all ADLs (activities of daily living) and needs turning/repositioning in the bed. This patient has significant limitations in functioning. The patient's bedbound status and needs, which include turning/repositioning, cannot be met with the approved CDPAS (consumer directed personal assistance services) 70 hours per week. These needs make it unlikely that the aide can get five hours daily of uninterrupted sleep during the aide's shift. The proposed CDPAS (consumer directed personal assistance services) 24 hours a day 7 days a week, split shift is appropriate and medically necessary to meet this patient's needs for assistance with ADLs (activities of daily living) and total care.