Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Incontinence. 
Treatment: Consumer Directed Personal Assistance Program (CDPAP) services, for a total amount of 7 days per week (24 hour [hr] live-in). 

The insurer denied Consumer Directed Personal Assistance Program (CDPAP) services, for a total amount of 7 days per week (24 hour [hr] live-in). 

The health plan's determination is overturned. 

This patient is a male with a medical history notable for dementia and incontinence. The patient receives 7.5 hours per day, 7 days per week (52.5 hours per week) of Consumer Directed Personal Assistance Program (CDPAP). The patient and his care team requested an increase to 24 hour per day (live-in) personal care services, 7 days per week. 

The patient's physician provided a letter. The letter states that the patient has diagnoses of hypertension, recurrent frequent hypotensive episodes with lightheadedness, severe generalized weakness, prostate cancer, vertigo, and fatigue. His condition is worsening, and he requires extensive assistance with bathing, cooking, and shopping. He has an unsteady gait with a history of frequent falls. He fell in the street last year and sustained metacarpal fractures and soft tissue injuries. Another fall resulted in a knee contusion which has further limited his ambulation. The physician requests 24-hour care for the patient given his need for assistance with ambulation at all times of the day and night. 

The patient's daughter provided a letter. The letter states that the patient has urinary incontinence and requires toileting several times overnight. Due to his mobility issues, he requires assistance with all toileting and transfers. He does not have any consistent informal support from his family. She requests 24-hour care to assist him with these needs throughout the day and night. 

A Uniform Assessment System (UAS) was completed. The assessment was conducted via teleconference. The patient lives alone in his apartment. The patient was alert and oriented to person and place only. His recall was 0/3 at five minutes and his procedural memory was not intact. He has a diagnosis of dementia, and his cognition was impaired. For his Instrumental activities of daily living (IADL)'s, he requires total dependence for housework. He requires maximal assistance for meal preparation, medications, and shopping. He requires extensive assistance for transportation, stairs, and finances. For his activities of daily living (ADL)'s, he requires maximal assistance for all (except for eating, which requires limited assistance). He requires significant weight-bearing assistance with his activities of daily living. He is frequently incontinent of urine and stool. He uses pullups for incontinence care. Compared to a prior UAS, he now requires more assistance for ADL's. A task tool associated with the assessment recommended 52.5 hours per week to address his personal care needs. 

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

The requested health service of increase in Consumer Directed Personal Assistance Program (CDPAP) services, for a total amount of 7 days per week (24 hr live-in) is medically necessary for this patient. 

The patient requires hands-on personal care assistance for all activities of daily living, including toileting, transfers, and ambulation. These personal care needs are expected to occur on an unscheduled and continuous basis throughout the day and occasionally at night. He cannot perform these tasks independently; his numerous falls while attempting tasks independently are evidence of his unmet personal care needs. The requested increase to a 24-hour live-in personal care aide is therefore medically necessary and appropriate for the patient. Failure to address his personal care needs could result in additional falls, skin breakdown, and/or infection.