Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 168 hours per week.
The insurer denied CDPAS 168 hours per week.
The determination is upheld.

This is a patient with a medical history notable for advanced dementia, coronary artery disease, and weakness. The patient is approved for Consumer Directed Personal Assistance Services (CDPAS) for 91 hours per week (live-in level of care). The patient and her care team requested an increase to 168 hours per week CDPAS (continuous care, split shift). This request was denied by the health plan.
A letter of support for this appeal was provided by the patient's physician. The physician feels that an increase in CDPAS hours is medically necessary. The patient has a recent history of wandering away from the home and having falls. She is "incapable of comprehending what is happening around her; incapable of making decisions; does not remember anything; wanders and often tries to leave the house." Additionally, the physician notes that she is unable to complete numerous activities of daily living including walking and toileting.
A letter of support for this appeal was provided by the patient's neurologist. The letter is substantially identical in content to the letter written by the physician above.
A letter of support for this appeal was also provided by the patient's son. The patient's son states that the patient awakens 1-3 times per night to urinate and that she needs assistance with toileting. She had recent urinary tract infections and vaginal infections due to improper attempts at doing her own hygiene care. She sometimes requires bathing/showering at night due to being soaked in urine, and is unable to safely do this by herself. She is unable to walk safely by herself and requires a contact person for security.
The discharge summary from a recent hospitalization was provided for review. The patient was admitted for metabolic encephalopathy secondary to a urinary tract infection with sepsis. She was treated and her mental status returned to baseline.
A Uniform Assessment System (UAS) was completed and was available for review. The patient's cognition was moderately impaired; she was oriented to person and place only and noted to be very forgetful. For her functional status, she requires total dependence for housework and shopping. She requires maximal assistance for managing finances, managing medications, phone use, and stairs. For her activities of daily living (ADLs), she requires extensive assistance for bathing, hygiene, dressing upper/lower body, toilet transfer, and toilet use. She requires limited assistance for walking and locomotion. She is independent with bed mobility and eating. She is occasionally incontinent of urine (less than daily) and continent of stool. At issue is the medical necessity of CDPAS 168 hours per week.

The requested health service/treatment of CDPAS 168 hours per week has not been demonstrated to be medically necessary for this patient.
The patient is approved for 91-hours CDPAS which is live-in level of care. Live-in aides are expected to get at least 5 hours of uninterrupted rest at night. If they have personal care needs that preclude a 5 hour rest window, then split-shift 24-hour care is more appropriate. The patient has some functional limitations but is still able to complete many tasks. She requires assistance with toileting. She is incontinent of urine occasionally (less than daily) and uses pull-ups. She does not require turning and positioning in bed. There is insufficient evidence that the patient has personal care needs that would preclude a 5-hour period of rest for her aide. The patient may require 24-hour care due to her dementia; however, the use of a home health aide for safety monitoring and security is not allowed as a personal care function when done as a standalone activity.