Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Incontinence/Urinary/Bladder Control
Treatment: Consumer Directed Personal Assistance (CDPA) Basic: 84 hrs per week
The health plan denied: Consumer Directed Personal Assistance (CDPA) Basic: 84 hrs per week
The determination is: Upheld

The patient is a female with a medical history notable for dementia and urinary incontinence. The patient is approved for 34 hours per week of consumer directed personal assistance (CDPA).
A physician's order for personal care increase was provided. It states that the patient needs oversight and supervision due to confusion. 
The patient's physician states that the patient has a history notable for hypertension, hyperlipidemia, hypothyroidism, osteopenia, dementia, depression, and vitamin deficiency. She sustained a fall at home and spent 6 months in inpatient rehabilitation. Since that time, she has had an unsteady gait and requires one person supervision with ambulation. She requires assistance with some instrumental activities of daily living (IADL) and activities of daily living (ADL) due to her dementia. She requires assistance with getting dressed due to upper extremity weakness. There have been instances of safety concerns such as leaving things on the stove for too long. She is incontinent of urine and wears Pull-Ups for incontinence care. The physician states that her current allotment of 32 hours of personal care per week are insufficient, and the physician feels that with the patient's comorbidities and dementia that she would benefit from additional help at home.
The patient's son (her consumer-directed personal care aide) provided a letter of support. The letter states that the patient needs supervision with dressing to ensure that she gets appropriate clothing for the weather. She needs supervision in eating to make sure that she does not eat too much or too little. She needs reminders to use her cane or walker when ambulating. She is supervised during showering to ensure her safety. The letter also describes some disagreements with a prior Uniform Assessment System (UAS). The family believes that the patient's level of assistance for finances and transportation should be total dependence (not maximal assistance as was noted). They also feel that the time allotment for toileting and meal preparation is inadequate. A proposed total of hours to complete all of the tasks required by the patient's son results in 90.25 hours per week of personal assistance.
A UAS was completed via teleconference with the patient's son present. She was alert and oriented with periods of confusion noted. Her short-term memory was not intact, and her insight and judgment were impaired. For her IADLs, the patient requires total dependence with finances. She requires maximal assistance with meal preparation, housework, medications, shopping, and transportation. She requires extensive assistance for phone use and stairs. For her ADLs, she requires extensive assistance for bathing, dressing her lower body, and toilet use. She requires limited assistance for hygiene, dressing her upper body, and toilet transfer.
At issue is the medical necessity of the CDPA 84 hours per week.
The health plan's determination of medical necessity is upheld in whole.
The requested health service of CDPA Basic: 84 hours per week is not medically necessary for this patient.
The patient's personal care needs revolve primarily around her dementia diagnosis. She is able to complete most ADLs with limited assistance or independently. She does require assistance with most IADLs. The additional time requested is primarily for safety monitoring and supervision. Although the patient may require continuous supervision throughout the day and night for her safety, this is not a task which is covered under policy. Safety monitoring and supervision can occur if they are secondary to a personal care function but are not approvable in the absence of a demonstrated personal care need.