Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia and depression
Treatment: Increase Consumer Directed Assistance Program (CDPAP) services live in per diem for a total of 24 hours/day, 7 days/week
The insurer denied an increase in CDPAP services live in per diem for a total of 24 hours/day, 7 days/week.
The denial is overturned.

The patient is an elderly female. Her conditions include Alzheimer's dementia and depression. She had a fall 3 months ago resulting in coccyodynia. Denial of an increase in consumer directed assistance program (CDPAP) services live in for a total of 24 hours/day, 7 days/week is being appealed. The health plan approved 4 hours/day, 7 days/week for a total of 28 hours/week.

The patient's Uniform Assessment System (UAS) evaluation performed 3 months ago shows moderately impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing medications, and shopping; extensive assistance with managing finances, bathing lower body, dressing, walking, locomotion, and toilet transfer; limited assistance with persona hygiene, upper body dressing, toilet use, bed mobility, and eating; and supervision with phone use. The patient has occasional bladder incontinence. Compared to UAS evaluation completed last year, there has been a decline with cognition, upper body dressing, personal hygiene, toilet use, and eating. A letter from the patient's daughter notes the patient's health has been declining. Additional hours are requested due to falls, assistance with medications, and assistance with doctor's appointments. The letter notes the mother needs 24-hour supervision and assistance with medications and transfer to the bathroom. Letters from the patient's provider note the patient needs assistance with most activities, including assistance with morning and night medications. The patient's dementia has progressed, and she is weaker. She has fallen. Additional hours are needed for assistance with ADLs (activities of daily living).

The requested increase in CDPAP services live in per diem for a total of 24 hours/day, 7 days/week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with ADLs, health maintenance activities, and routine support services. Denial of an increase in CDPAP services live in for a total of 24 hours/day, 7 days/week is being appealed. The health plan approved 4 hours/day, 7 days/week for a total of 28 hours/week. The plan denied the request based on the most recent UAS evaluations and notes the patient's personal care needs can continue to be met with the currently approved hours. This patient has chronic conditions, including Alzheimer's dementia. The patient's UAS evaluation performed 3 months ago shows moderately impaired cognition. She requires assistance with all ADLs. Compared to UAS evaluation completed last year, there has been a decline with cognition, upper body dressing, personal hygiene, toilet use, and eating. She has occasional bladder incontinence. The appeal statements support a decline in the patient's functioning and need for assistance with ADLs. The information provided supports that the patient has significant impairments. Her functioning has declined between UAS evaluations. The approved CDPAP at 28 hours/week is insufficient to meet the patient's needs. The requested increase in CDPAP to live in for a total of 24 hours/day, 7 days/week is medically necessary to meet this patient's needs for assistance with ADLs.