Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System/Other/Hypoxemia.
Treatment: Home Health Care/Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) for a total of 168 hours per week. 
The health plan denied the requested Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) for a total of 168 hours per week as not medically necessary. 
The health plan's determination is overturned.

This is a case review for a male with a medical history notable for hypertensive heart disease, fecal and urinary incontinence, and advanced dementia. The patient is approved for 8 hours per day, 7 days per week (56 hours per week) of (CDPAP) consumer directed personal assistance program. 
The patient is currently residing at a skilled nursing facility. According to a letter from a community advocate, he cannot be safely discharged until appropriate home care is arranged. A letter from his wife's physician states that his wife is not able to provide any informal care to the patient due to her own medical conditions. Any help he receives would have to come from a personal care assistant.
A letter of support for this review was provided by the patient's nurse practitioner. The letter states that the patient has had cognitive decline from dementia. He has urinary and fecal incontinence and has multiple daytime and night soiled diapers and linens. The letter states he requires human assistance for activities of daily living due to his rapid physical and cognitive decline.
Nursing notes and occupational therapy notes from his current skilled nursing facility were provided and reviewed in detail for this case review. There was no documentation from the treating physician or discharge disposition provided.
A Uniform Assessment System (UAS) was completed and was available for review. The review was completed while the patient was in the skilled nursing facility. Cognition was noted to be severely impaired; he was alert and oriented to person only. Recall was 1/3 at five minutes. He is not able to direct his own care. From a functional standpoint, he requires total dependence for most instrumental activities of daily living (IADL) including meal preparation, housework, managing finances, managing medications, stairs, transportation, and shopping. For his activities of daily living (ADLs) he requires total dependence for almost all including bathing, hygiene, dressing lower body, walking, locomotion, toilet transfer, toilet use bed mobility, and eating. He is frequently incontinent of urine and stool. Compared with a prior assessment, he showed decline in both cognition and functional status.

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

The requested health service/treatment of Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) for a total of 168 hours per week is medically necessary for this patient.
The patient is unable to complete any ADL's or IADL's without total dependence on others for help. He is incontinent of stool and urine. He is unable to direct his own care. He will require hands on assistance from a personal care aide 24 hours per day continuously to provide for incontinence care. Failure to provide for these personal needs could lead to skin breakdown and/or infection. He is not able to direct his own care and cannot be left in soiled diapers overnight.
There is no documentation provided from the physician at the skilled nursing facility regarding whether or not discharge home with home health aide is appropriate versus remaining in the skilled nursing facility; this will be up to the physician's clinical judgement in concert with the patient and his family's wishes.