Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Congestive Heart Failure
Treatment: Home Health Care/Consumer Directed Personal Assistance Services (CDPAS) 24-hour live in, 7 days per week. 

The health plan denied the requested Consumer Directed Personal Assistance Services (CDPAS) 24-hour live in, 7 days per week as not medically necessary. The health plan's determination is overturned. 

This is a case review for a female with medical history notable for congestive heart failure, incontinence of bowel and bladder, and repeated falls. The patient is approved for 56 hours per week of consumer directed personal assistance services (CDPAS). 
The patient is on hospice care for end-stage congestive heart failure. Her nurse practitioner requested additional hours because she requires assistance with all activities of daily living (ADL). The patient is alert and oriented but does have periods of confusion. Hospice notes were reviewed in detail. 
The patient's daughter provided a letter of support for this appeal. The letter states that even if the patient tries to ambulate short distances with her walker (without human assistance) she has fallen and cannot get up without help; this has resulted in ambulance calls in the past. She requires assistance with daily activities including toileting and diaper changes. Her cognition has started to decline over the past few years. 
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference. The patient lives alone in her home. She was alert and oriented times three; her short term and procedural memory was intact. For her instrumental activities of daily living (IADL), she requires total dependence for meal preparation and housework. She requires maximal assistance for phone use, stairs, shopping, and transportation. For her ADL, she requires maximal assistance for bathing and dressing lower body. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, and toilet transfer. She requires limited assistance for toilet use and bed mobility. She is frequently incontinent of urine and occasionally incontinent of stool. She requires 4-6 changes of incontinence products daily. The patient's functional status is limited by her end stage heart failure which causes shortness of breath with any level of exertion. 
At issue is the medical necessity for the requested health service/treatment of Consumer Directed Personal Assistance Services (CDPAS) 24-hour live in. 

The health plan's determination of medical necessity is overturned, in whole. 

The requested health service of Consumer Directed Personal Assistance Services (CDPAS) 24-hour live in is medically necessary for this patient. 

The patient is of advanced age and is very limited from a functional standpoint from end-stage congestive heart failure. She requires hands-on assistance with all ADL's including ambulating, transfers, and toileting. These needs can be expected to be unscheduled and continuous throughout the day and occur less frequently at night. She is also incontinent of urine and stool and requires assistance with several diaper changes per day. Her falls are evidence of unmet personal care needs. Therefore, the requested increase to a live-in personal care aide is medically necessary and reasonable for the patient.