Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, atrial fibrillation, coronary artery disease, hypertension, gastroesophageal reflux disease, shoulder/knee pain, asthma and obstructive sleep apnea.
Treatment: Increase Consumer Directed Personal Assistance Service (CDPAS) for 168 Hours Weekly.
The insurer denied the Increase Consumer Directed Personal Assistance Service (CDPAS) for 168 Hours Weekly.
The denial is upheld.

This female has medical conditions including dementia, atrial fibrillation, coronary artery disease, hypertension (HTN) gastroesophageal reflux disease (GERD), shoulder/knee pain, asthma and obstructive sleep apnea.  This is an appeal for denial of 168 consumer directed personal assistance services (CDPAS) hours per week, which was requested primarily for supervision and oversight.  The patient has been approved for change from 68 to 84 hours per week.  

The daughter notes her mother needs more hours and more care.  She needs assistance at night for safety reasons.  The  daughter notes the patient's dementia has worsened.  The patient lives with her daughter who is a direct paid caregiver.  The patient is not left alone.  The family only wants family to provide care.  A clinical note notes the patient would benefit from 24 hour consumer directed personal assistance services (CDPAS).  Clinical note states the patient's dementia has worsened and the daughter is watching her mother 24/7.  The patient is not able to walk alone; she is worse at night.  There are reports of crying.  There is intermittent urinary incontinence. The patient is taking her oxygen off at night.  Clinical note states a 24 hour aid is supported, particularly as a fall risk at night when she is confused and needs reorientation.

No, the proposed treatment is not medically necessary.
Medically necessary services are those which are:
1) safe.  2)effective. 3) generally accepted national standard of medical practice. 4) not provided primarily for convenience of the patient or the practitioner. 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is not medically necessary because it is not consistent with generally accepted national standard of medical practice.

Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  

This patient was approved for 84 personal assistance service (PAS) hours per week and is appealing the denial of an increase to 168 hours per week.  This patient has several chronic conditions including dementia.  She lives with her daughter, who is her caregiver.  The family has decided to provide care/support to the patient.  The patient is never left alone.  Her daughter is requesting an increase in consumer directed personal assistance services (CDPAS) to 168 hours per week due to the patient's cognitive decline being worse at night.  The daughter notes that the patient needs more assistance for safety concerns.  Clinical notes from providers verify dementia and that the patient requires reorientation at night.  There is no documentation of significant decline in functioning.  Personal assistance services (PAS) are not indicated when there are no tasks being performed or for supervision.  The approved for 84 hours per week is sufficient to meet this patient's needs for assistance with the support of her paid caregiver and informal support of other family.  The proposed increase in personal assistance services (PAS) to a total 168 hours per week is not medically necessary.