Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive Decline.
Treatment: Increase to 24 hours per day (split shift), 7 days per week. Total 168 hours per week consumer directed personal assistance services (CDPAS).
The insurer denied an increase to 24 hours per day (split shift), 7 days per week. Total 168 hours per week consumer directed personal assistance services (CDPAS).
The determination is overturned.

The patient has a past medical history of seizure disorder, oxygen dependence, dementia, coronary artery disease, urinary tract infections, chronic obstructive pulmonary disease (COPD), hypertension, hyperlipidemia, left ankle fracture, anxiety, depression, congestive heart failure, diabetes mellitus, urinary incontinence and bowel incontinence who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 6 hours/day, 7 days/week, to total 42 hours/week based on an assessment tool performed assessing the patient at maximum assistance with the tasks of meal preparation and ordinary housework while extensive assistance with tasks of stairs, shopping, transportation, and bathing. The patient was assessed at limited assistance with the tasks of managing medication, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. With the tasks of managing finances and phone use, the patient was assessed at set up only while independent with the tasks of bed mobility and eating. The patient had a fall with left ankle fracture with a subsequent rehabilitation stay.
The patient had an assessment tool performed while in a Skilled Nursing Facility (SNF) and was assessed at total assistance with the tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, bathing, dressing lower body, locomotion, and toilet use while maximum assistance with tasks of managing medication, phone use, equipment management, personal hygiene, and bed mobility. Activity did not occur for the tasks of walking and transfer toilet. Notes from this assessment stated the patient was moderately impaired cognitively and had no informal help.
Physical therapy (PT) and occupational therapy (OT) notes from rehabilitation noted the patient was totally dependent for bed mobility, transfers, stairs, ambulation, lying to sitting, sit to lying, rolling left to right, sit to stand, toilet transfer, bathing, toileting, upper extremity (UE) / lower extremity (LE) dressing, and positioning and repositioning self.
The insurer sent a final adverse determination notice denying the request to increase CDPAP services stating the patient was confused, needed constant supervision, was at risk for falling when attempting to get out of the wheelchair, was at the correct and safe level of care in nursing home, would be at risk for her safety if care were given in her home, and was not safe in her home until this problem is corrected.
The rehabilitation facility/SNF sent a letter stating the patient resides alone, had a significant decline in cognitive, functional and medical status, required total care with all toileting and diaper change on an hourly basis, required frequent toileting and changing in order to prevent a urinary tract infection (UTI), required use of a Hoyer lift for transfers due to non-weight bearing status. The letter also stated the patient was at high risk for falls, has episodes of anxiety and confusion with difficulty sleeping at night, has a history of skin breakdown and bed sores and requires to be turned and positioned at least every two hours in order to prevent any and all skin breakdown or bed sores. In addition, the provider strongly recommended the patient receive 24 hours/day, 7 days/week via 12 and 12 split shift in order to safely return and remain in the community and it was unlikely an aide or attendant would be able to get any consecutive hours of sleep due to the patient's care needs.The patient's family appealed the insurer's denial decision.
At issue is the medical necessity of an increase to 24 hours per day (split shift), 7 days per week. Total 168 hours per week consumer directed personal assistance services (CDPAS).
The services are medically necessary.

There is documented cognitive and functional decline with the patient following her ankle fracture and hospitalization. The patient's medical provider recommended 24 hour care in split shifts due to her complex medical needs. The patient does not require skilled nursing services. The patient has no informal help. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested CDPAP services are not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The patient's medical provider has ordered change of diaper and repositioning at least every 2 hours and therefore, an aide would not be able to obtain 5 hours of uninterrupted sleep in the overnight hours.
Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 24 hours/day, split-shift 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.