Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Increase in Consumer Directed Personal Assistance Services (CDPAS) from 7 days per week, 9 hours per day; 63 hours per week to 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person of Consumer Directed Personal Assistance Services (CDPAS).
The insurer denied the increase in Consumer Directed Personal Assistance Services (CDPAS) from 7 days per week, 9 hours per day; 63 hours per week to 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person of Consumer Directed Personal Assistance Services (CDPAS).
The health plan's determination is upheld.

The patient is a female with a medical history notable for congestive heart failure and dementia. The patient is approved for 9 hours per day, 7 days per week (63 hours per week) of Consumer Directed Personal Assistance Services (CDPAS). The patient and her care team requested an increase to 24 hours per day (continuous care by more than one person), 7 days per week (168 hours per week).
The patient's primary care physician provided a letter of support for this appeal. The letter states that the patient has a medical history notable for dementia, dilated cardiomyopathy, hypertension, dyslipidemia, and hypothyroidism. The letter states that she requires assistance with daily tasks such as bathing, cooking, housekeeping, and medications. There is no discussion of currently unmet personal care needs.
The patient has multiple recent hospitalizations related to anemia from epistaxis. The note states that "she definitely needs 24-hour home care services" but does not describe which personal care needs are not being met.
A Uniform Assessment System (UAS) that was completed notes the patient lives with her son and granddaughter in an apartment. The patient is alert to person and place only. She has forgetfulness and frequent confusion. Her short-term and procedural memory was not intact. Her mini-mental state examination (MMSE) score was 6 out of 30, consistent with severe dementia. For her Instrumental activities of daily living, she requires total dependence for housework, finances, and shopping. She requires maximal assistance for meal preparation, medications, phone use, stairs, and transportation. For her activities of daily living (ADL), she requires maximal assistance for bathing, dressing lower body, walking, locomotion, toilet transfers, and toilet use. She requires extensive assistance for hygiene, dressing upper body, bed mobility, and eating. She is frequently incontinent of urine and stool and wears pullups for incontinence care. A task tool associated with the UAS recommended 38.3 hours per week to address her personal care needs.
The case notes state that the patient's granddaughter does not get home early enough and the patient is home alone for a time period between when her aides leave and family returns. The family states that the patient's functional status has been worse following a hospitalization with one week in the Intensive Care Unit (ICU).
 
The patient had advanced dementia and incontinence. She has had multiple recent hospitalizations and a functional decline. The documentation does not detail which personal care needs, if any, are not currently being met. The physician's letter and notes reference an increase in hours, but do not state why. Continuous 24 hour care is considered medically necessary only for patients that have demonstrated personal care needs throughout the day and night, such as toileting or turning/repositioning to promote healing of a pressure ulcer. Because there is no documentation of her needs, it is not clear whether the patient requires additional continuous personal care hours (daytime and nighttime) versus some other type of support such as skilled care. The patient is approved for 63 hours per week of CDPAS which is greater than the amount recommended by the task tool.