Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Falls, Fracture
Treatment: Consumer personal assistance services (CDPAS) 24 hours a day (split-shift), 7 days a week (continuation)
The insurer denied consumer personal assistance services (CDPAS) 24 hours a day (split-shift), 7 days a week (continuation).
The determination is upheld.

This is a female patient with a past medical history of diabetes mellitus type 2, permanent pacemaker, hypertension, macular degeneration, lower extremity edema, urinary incontinence, frequent urinary tract infections (UTIs), anxiety, depression, osteoarthritis, vertigo, and recurrent falls who had a fall with humeral fracture. Following this fall, the patient had 24 hours/day, 7 days/week aide care by private pay.
A social worker provided documentation to support home health aide services. The social work assessment stated the patient lives in a Colonial split private house and the patient lived on the first floor with private pay 24hours/day, 7 days/week aide care and could not afford to continue this care. The social work assessment also stated the patient desired to remain in her own home, the patient was lucid, the family was hoping to transition current aide services to Consumer Directed Personal Assistance Services (CDPAS) program, and the patient had a hospital bed and the aide slept on the couch in the same room.
In addition, the social work assessment stated the family had to reduce services due to cost and the patient's aide was arriving when the patient was typically already out of bed and on the toilet because of sense of urgency and the patient has been holding in her urine as to not need to go to the bathroom in the overnight hours which has led to urinary tract infections. The patient's medical provider completed Department of Health (DOH) form 4359 stating the patient's prior humeral fracture impacted the patient's activities of daily living (ADL) status, the patient had issues with balance and was unsteady even with a walker, the patient would benefit from physical therapy, the patient would benefit from monitoring of her diabetes, the patient needed close supervision and contact guarding with all mobility, the patient lived alone, the patient was able to direct her own care, the patient had recurrent falls, and the patient needed assistance with showering, toileting, dressing, undressing, transferring, grooming, meal preparation, and light housekeeping.
The patient underwent an assessment via video on assessing the patient at total assistance with tasks of meal preparation and ordinary housework while maximum assistance with tasks of managing finances, stairs, shopping, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. With tasks of managing medication, phone use, bed mobility, and eating the patient was assessed at extensive assistance. The assessment also stated the patient tried to hold her urine until the morning so that she would have assistance, the patient's activities of daily living (ADL) status had declined over the last 90 days and there was a deterioration of overall self-sufficiency in the last 90 days.
The insurer sent an initial adverse determination notice to reduce, suspend, or stop services approving 63 hours of CDPAP services per week. The patient's physician provided DOH form 4359 stating patient has frequent UTIs, recurrent chronic cough, and balance issues causing major concerns about falling again, the patient's earlier medical needs were the same, and the patient's safety would benefit much from more personal care preventing her latest change in condition from getting worse. The insurer sent a final adverse determination denial notice partially denying the request to increase CDPAP services approving CDPAP services 24 hours/day, live-in, 7 days/week. The denial stated plan recommended splitting hours to best meet her needs, an aide could help care needs including position changes 2-3 times per night, and services were not provided for safety and supervision.
The patient's primary care provider provided a letter of medical necessity stating the patient would benefit from increased personal care due to recurrent chronic cough, frequent UTIs causing confusion and poor judgment and balance issues, along with other conditions noted in the previous report. The provider also stated the need did come consistent glucose monitoring due to diabetes and patient had severe anxiety and depression and lack of sleep increasing the risk of falls in the early morning and during the night and her medications were in the process of being addressed. The patient's son provided a letter requesting an external appeal noting that the patient lived alone (Uniform Assessment System (UAS) incorrectly stated the patient lived with her son), the patient had balance issues, the patient had recurrent falls, the patient had poor judgment and confusion due to urinary tract infections, the patient had increased anxiety and depression at times, the patient was diabetic and needed constant glucose monitoring, and the patient needed help to safely remain in her home. Lastly, the son's letter stated they were asking for 16 hours a day to protect the safety of their mother and protect her from a fatal fall. The patient's primary care physician (or provider) (PCP) appealed the denial decision. At issue is the medical necessity of consumer personal assistance services (CDPAS) 24 hours a day (split-shift), 7 days a week (continuation).
The services are not medically necessary. The patient's care needs can be met with CDPAP services 24 hours/day, live in, 7 days/week. There was no documentation of a need for frequent repositioning at least every 2 hours overnight. There was no specific documentation with overnight care logs of assistance needs with ADLs which would not allow a CDPAP service aide to obtain at least 5 hours of uninterrupted sleep. There is documentation from the patient's primary care physician (or provider) (PCP) and son that the patient requires "constant" glucose monitoring with no specific reason (i.e. insulin use, frequent hyperglycemia) or a specific schedule of glucose monitoring in the overnight hours that would not allow a CDPAP service aide to obtain at least 5 hours of uninterrupted sleep. 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 a day (split-shift), 7 days a week are not medically necessary for this patient.