Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atherosclerotic heart disease, hypertension, hemiplegia and hemiparesis following cerebral infraction affecting right dominant side, hyperlipidemia, osteoarthritis, vascular dementia with behavioral disturbance, and vitamin deficiency
Treatment: Increase in Consumer Directed Personal Assistance Program (CDPAP) services, in the amount of 168 hours/week
The insurer denied the increase in CDPAP services, in the amount of 168 hours/week.
The denial is overturned.

The patient is an adult male. His medical conditions including atherosclerotic heart disease, hypertension, hemiplegia and hemiparesis following cerebral infraction affecting right dominant side, hyperlipidemia, osteoarthritis, vascular dementia with behavioral disturbance, and vitamin deficiency. He is homebound. The denial of an increase in consumer directed personal assistance program (CDPAP) in the amount of 168 hours/week, split shift, is being appealed. The health plan partially approved the request and increased CDPAP from 66.5 hours/week to 24 hours/day, live in, 7 days/week.

Uniform Assessment System (UAS) evaluation completed 7 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, phone use, shopping, personal hygiene, lower body dressing, locomotion, and toilet use; and maximal assistance with bathing, upper body dressing, walking, toilet transfer, bed mobility, and eating. The patient uses a wheelchair for locomotion. He is incontinent of bowel and bladder. Compared to UAS evaluation completed previously, there has been a decline with dressing, personal hygiene, toilet use, locomotion, eating, and bed mobility. The patient was admitted to rehabilitation.

An appeal statement from the provider notes the patient's medical conditions have worsened. He requires assistance with ADLs (activities of daily living) throughout the day and night and requires repositioning every two to three hours. A Night-Time Log shows care being provided during day and night. A letter from the patient's provider recommends 24 hours split shifts. They note the patient is bedbound and requires turning and repositioning every two to three hours to prevent skin breakdown.

The requested increase in CDPAP in the amount of 168 hours/week 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. Denial of an increase in CDPAP in the amount of 168 hours/week, split shift, is being appealed. The health plan partially approved the request and increased CDPAP from 66.5 hours/week to 24 hours/day, live in, 7 days/week. The approved CDPAP services for a total of 24 hours/day, live in, is insufficient to meet the patient's needs. The requested CDPAP services for a total of 168 hours/week, split shift, is medically necessary.