Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer directed personal assistant services (CDPAS) 24 hours/day, 7 days/week (split-shift)
The insurer denied CDPAS 24 hours/day, 7 days/week (split-shift).
The determination is overturned.

This is a female patient with a medical history notable for dementia. The patient was previously approved for 24 hours/day (split-shift) consumer directed personal assistant services (CDPAS) for a total of 168 hours/week. The health plan decided to reduce the services from split-shift to 24-hour live-in personal care, for a total of 91 hours/week.

The patient's physician provided a letter of support for this appeal. The physician treats the patient at a wound care center. The patient has type 2 diabetes, prior heart valve surgery, and prior cerebrovascular accident. She has an open wound on the right foot. The patient is unable to walk, has contractures of the extremities, and is bedridden. She is unable to turn and position herself in bed to aid with healing. The physician states that the patient requires 24 hours/day care, including overnight care to assist with turning and repositioning to promote wound healing.

Another of the patient's physicians provided a letter of support for this appeal. The letter states that the patient requires assistance with all activities of daily living (ADLs), including turning and repositioning every 2 hours to promote healing of pressure wounds on the bilateral feet. Therefore, the physician requests 24-hour split-shift care.

A Uniform Assessment System (UAS) was completed via video teleconference. The patient lives in her home with her spouse. The patient was alert and oriented to person and place only. She was very forgetful with frequent confusion. For her instrumental activities of daily living (IADLs), she requires maximal assistance or total dependence for all. For her ADLs, she requires total dependence for essentially all activities with the exception of eating (for which she requires maximal assistance). She is incontinent of both urine and stool with no control present. At issue is the medical necessity of CDPAS 24 hours/day, 7 days/week (split-shift).

The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5-hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate. Therefore, the issue is whether the patient's personal care needs are expected or known to occur with such frequency to preclude the required rest window for a live-in aide.
Based on the documentation provided, the patient's personal care needs are continuous throughout any given 24-hour period and would preclude adequate rest for a live-in personal care assistant. The patient requires turning and repositioning every 2 hours around the clock to promote healing of her pressure wounds and prevent development of additional wounds. She is also incontinent of both urine and stool and unable to direct her own incontinence care. She will require prompt recognition and assistance with diaper changes after episodes of incontinence. This will lead to additional unscheduled needs overnight. Therefore, the requested service of split-shift personal care is medically necessary for the patient.