Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia.
Treatment: Increase Consumer And Self Directed Personal Assistance Services 24 Hours a day, 7 days a week (split-shift) For A Total of 168 hours per week.
The insurer denied the Increase Consumer And Self Directed Personal Assistance Services 24 Hours a day, 7 days a week (split-shift) For A Total of 168 hours per week.
The denial is upheld.

The patient is a female with medical conditions including dementia.  She lives alone with support of grandson.  This is an appeal for denial of Increase in Consumer and Self Directed Personal Assistance Services to 24 hours a day, 7 days a week, split-shift, total of 168 hours per week.  She has been approved for CDPAS (consumer directed personal assistance services) at 84 hours per week.

The patient's grandson states that she needs overnight services for safety due to frequent falls at night.  An UAS (Uniform Assessment System) evaluation showed the patient needs assistance with meal preparation, housekeeping, laundry, shopping, dressing, personal hygiene, toiling, bathing, bed mobility, and eating.  She has bowel and bladder incontinence.  A physician's order for CDPAS (consumer directed personal assistance services) notes the patient has severe dementia and arthritis.  She is wheelchair-bound and needs complete help. A letter from the provider states the patient's Alzheimer's disease is getting worse and she is requiring more help.

No, the requested increase in consumer directed personal assistance services to 168 hours/week is not medically necessary.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the provider five hours daily of uninterrupted sleep during the aide's shift.

This patient has medical conditions including dementia and arthritis. This is an appeal for denial of Increase in Consumer and Self Directed Personal Assistance Services to 24 hours a day, 7 days a week, split-shift, total of 168 hours per week. She has been approved for CDPAS (consumer directed personal assistance services) 84 hours per week.

UAS (Uniform Assessment System) evaluation shows the patient needs assistance with meal preparation, housekeeping, laundry, shopping, dressing, personal hygiene, toiling, bathing, bed mobility, and eating. Appeal statements from the patient's grandson and physician are requesting additional hours due to progressive dementia and overnight services for safety. The documentation does not support that the patient has need for continuous uninterrupted care needs for assistance with ADLs (activities of daily living). PAS (personal assistance service) is not indicated for supervision or when no tasks are being performed. The approved CDPAS (consumer directed personal assistance services) 84 hours per week is sufficient to provide aid with ADLs (activities of daily living) and personal care as noted above. The proposed CDPAS (consumer directed personal assistance services) 24 hours a day, 7 days a week, split-shift, total of 168 hours per week is not medically necessary.