Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Fall risk.
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 24 hours per day, continuous care by more than one person, 168 hours per week.

The insurer denied Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 24 hours per day, continuous care by more than one person, 168 hours per week.
The determination is overturned.

The patient has a past medical history of dementia, hypertension, atrial fibrillation, coronary artery disease, osteoarthritis, osteoporosis, history of falls, anemia, insomnia, asthma, chronic obstructive pulmonary disease (COPD), history of cerebrovascular accident (CVA), oxygen dependence, constipation, recurrent urinary tract infection (UTI), urinary incontinence, bowel incontinence and anxiety who had been assigned consumer directed personal assistance program (CDPAP) services 12 hours/day, 7 days/week, to total 84 hours/week. There was a request to increase the CDPAP services, and the patient underwent a telephonic assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, phone use, shopping, transportation, bathing, and toilet use while maximum assistance with the tasks of managing medication, stairs, equipment management, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, bed mobility, and eating. Notes from the assessment stated the patient's activities of daily living (ADL) status and self-sufficiency had declined and deteriorated. The patient's daughter noted her to have a small area of redness on the sacrum.

The patient was approved for CDPAP services 24 hours/day, live-in, 7 days/week. The patient was hospitalized following a fall at home with subsequent rib fracture requiring chest tube, treatment of hyponatremia, and treatment of aspiration pneumonia. There was a request to increase CDPAP services to 24 hours/day, split shift, 7 days/week, to total 168 hours/week. The insurer sent an initial adverse determination denial notice denying the request to increase CDPAP services.

The insurer sent a final adverse determination denial notice denying the request to increase CDPAP services stating the request was not medically necessary and the patient did not meet criteria. The denial also stated that the most recent rehabilitation notes documented the patient was able to make her needs known, was able to walk 2-3 steps, and was able to transfer with moderate and close help with 1 person.

The patient's daughter provided a letter stating the patient's condition had declined over the past several months, had incontinence and needed to be changed often to prevent bedsores, suffered from recurrent urinary tract infections (UTIs), was unable to summon help by any means due to cognitive decline, was unable to get a drink of water unassisted and was unable to use her asthma rescue inhaler without assistance. The daughter also noted the patient had developed severe bedsores on her buttock and the heels of her feet which had not healed and was developing new sores because she was unable to change positions without the daughter's help at home. In addition, the daughter's letter stated the patient often forgets she needs help getting out of bed and tries to do so on her own and has fallen several times. Lastly, the daughter herself noted she has not had an uninterrupted night of sleep as she has been up every 4 hours at night to assist the patient with changing, turning, cleaning, bandaging bedsores, offering water, and providing assistance with rescue inhaler.

The patient's primary care physician (or provider) (PCP) provided a letter that patient was homebound and bedbound, was unable to summon help by any means, was unable to perform any activities of daily living (ADLs) or instrumental activities of daily living (IADLs), needed to be turned and repositioned every 2 hours to prevent pressure ulcers, had urinary incontinence, needed diapers to be changed frequently to avoid skin breakdown, and needed 12 x 12 hours, 7 days/week of CPDAP services to help her with her ADLs and IADLs and to prevent the occurrence of the many complications and to optimize her quality of life. The patient's healthcare advocate provided a letter requesting external appeal of insurance denial decision. The letter stated that the patient lived with her daughter and son-in-law but they were unable to provide the amount of care the patient required.

At issue is the medical necessity of consumer directed personal assistance services (CDPAS) 7 days per week, 24 hours per day, continuous care by more than one person, 168 hours per week.

The services are medically necessary.

The patient has documented chronic and progressive medical conditions of dementia with urinary and bowel incontinence. The patient had a hospitalization with worsening in cognitive and functional status with an increased need of assistance with ADLs and IADLs. She requires turning and repositioning frequently, changing of diapers promptly due to skin breakdown and recurrent UTIs, and assistance with her asthma inhaler in the nighttime hours. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not develop a plan to meet the patient's unpredictable and unscheduled care needs. The plan assumed the family could provide informal support to meet the patient's needs. The patient's current CDPAP services and/or adaptive equipment and/or medical supplies are not sufficient to meet the patient's ADL and IADL needs. The requested increase in CDPAP hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. 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. CDPAP and 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.