Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: Increase Consumer Directed Personal Care Assistance Services 24 Hours Per Day 7 Days Per Week (split shift) A Total of 168 Hours Per Week (The health plan approved 60 hours/week)
Increase Consumer Directed Personal Care Assistance Services 24 Hours Per Day 7 Days Per Week (split shift) A Total of 168 Hours Per Week (The health plan approved 60 hours/week)
The insurer denied the Increase Consumer Directed Personal Care Assistance Services 24 Hours Per Day 7 Days Per Week (split shift) A Total of 168 Hours Per Week (The health plan approved 60 hours/week)
The denial is overturned

This male has conditions including stroke with right-sided hemiparesis, Alzheimer's diseased, aphasia, Parkinson's disease, osteoarthritis, normal pressure hydrocephalus, and hypertension. He is appealing denial of increase consumer directed personal care assistance services (CDPAS) 24 hours per day 7 days per week, split shift, a total of 168 hours per week.  The health plan approved 60 hours/week.  Uniform Assessment System (UAS) evaluation performed shows moderately impaired cognition and functional status is total dependence with ADLs and personal care.  He has frequent bowel and bladder incontinence.  A Hoyer lift is used for transfers.	

A letter from the provider notes the member has clinical and functional deficits after recent hospitalization for stroke and pneumonia.  Since discharge, the member is diaper dependent and requires PEG (percutaneous endoscopic gastrostomy) tube feeding.  He is bedbound and wheelchair dependent.  He is unable to move himself and is at risk for bedsores.  

Clinical notes indicate the member needs full assist and requires turning and repositioning.

Yes. The proposed treatment is 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 aide five hours daily of uninterrupted sleep during the aide's shift. This member is status post recent stroke with residual hemiparesis, aphasia, and dysphagia.  The multiple chronic medical conditions, including Alzheimer's dementia and Parkinson's disease.  He is appealing denial of increase CDPAS (consumer directed personal care assistance services) 24 hours per day 7 days per week, split shift, a total of 168 hours per week.  The health plan approved 60 hours/week.  UAS (Uniform Assessment System) evaluation completed shows the member requires total assistance with all ADLs (activities of daily living) and personal care.  He has bowel and bladder incontinence.  Appeal statements and clinical records show the member's conditions has deteriorated since the stroke.  He is bed and wheelchair bound.  He requires assistance with turning and repositioning.  The information provided shows that the member is significantly limited and totally dependent.  His needs for assistance with all ADLs iADLs (activities of daily living/ instrumental activities of daily living) and need for repositioning/turning cannot be met with the approved CDPAS (consumer directed personal care assistance services) 60 hours/week.  The member needs for 24 hour care would not allow an aide to get five hours daily of uninterrupted sleep during the aide's shift. The proposed increase in CDPAS (consumer directed personal care assistance services) to 24 hours per day 7 days per week, split shift, a total of 168 hours per week is medically necessary.

No. The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.