Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metabolic Encephalopathy
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Services: Split Shift, Total of 168 Hours per Week [12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week]

The health plan denied: Consumer Directed Personal Assistance Program (CDPAP) Services: Split Shift, Total of 168 Hours per Week [12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week]
The determination is: Upheld

The patient is a female with a medical history notable for severe memory loss, bedbound status, and incontinence. The patient is approved for 6 hours per day, 7 days per week (42 hours per week) of consumer directed personal assistance program (CDPAP) personal care services. 

The patient is currently residing in a nursing home where she has been receiving short term rehabilitation. Prior to admission, she was living alone in an apartment and was doing well with 42 hours per week of personal care. She was admitted after a syncopal episode with fall and left intraventricular hemorrhage.

The patient's physician provided a letter of support for this appeal. The letter states that the patient has had a significant decline in her medical, cognitive, and functional status. She requires assistance with transfers, toileting, diaper changes, and bathing. The physician notes that "she is not safe to be left alone at all and is having frequent episodes of anxiety and confusion with difficulty sleeping through the night." The physician furthermore notes that "it is unlikely that an attendant will be able to get any consecutive hours of uninterrupted sleep."

A community advocate provided a letter of support for this appeal. The letter states that the patient is awaiting increased hours for a safe discharge. She describes the patient as bed bound. She requires assistance with diaper changes.

The health plan denied the requested increase. They state that they reached out to the case manager of the nursing home, and there was not a discharge plan in place. They will not approve of any increase until a safe discharge plan is put into place.

A Uniform Assessment System (UAS) was available for review. At that time, the patient was alert and oriented. She required extensive-maximal assistance for instrumental activities of daily living (IADL). She required limited-extensive assistance for activities of daily living (ADL). At that time, she had only occasional incontinence.

Progress notes were provided for review. The patient does not have any evidence of pressure ulcers. She can walk in the corridor and in her room with supervision assistance for setup help only. Many ADL tasks were completed with supervision only or stand by assistance.

At issue is the medical necessity of CDPAP Services: Split Shift, Total of 168 Hours per Week.

The health plan's determination of medical necessity is upheld in whole.

The requested health service is not medically necessary for this patient.

The patient has had a significant functional decline following her fall with resulting intracerebral hemorrhage. She will almost certainly require additional assistance in the home if she can be safely discharged. However, there is insufficient evidence that the patient requires 24-hour split shift personal care. The patient is able to participate in some ADL's. In some letters her status is described as bed-bound, although that does not appear to be the case based on therapy notes from the nursing home. The physician caring for her requests overnight coverage due to difficulty with sleeping and anxiety in the patient, but personal care aides cannot be approved for the sole purposes of safety monitoring and security. There has not been an updated UAS performed since her hospitalization and recovery. Therefore, there is insufficient evidence to support the medical necessity for 24-hour split-shift care.