Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Alzheimer's Dementia, Congestive Heart Failure, Diabetes, Hypertension, Right Knee Arthritis.
Treatment:  Consumer Directed Personal Assistance Services (CDPAS) 24 hours per day, 7 days per week (split shift); a total of 168 hours per week.

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS) 24 hours per day, 7 days per week (split shift); a total of 168 hours per week.  
The denial is upheld.

This case involves a geriatric patient with a request for increase in personal assistant hours. The Summary Report reported the patient had frequent bladder incontinence, and cognition was moderately impaired. The patient had difficulty with balance and utilized a wheelchair. The patient required assistance with meal preparation, ordinary housework, shopping, transportation, managing medications, bathing, personal hygiene, dressing, toilet transfer, locomotion, and eating. Total task hours were 40.89. The most recent Summary Report indicated overall total hours were 66.35. 

Appeal application reported that the patient required 2 aids with 12-hour service each due to Alzheimer dementia, multiple chronic medical conditions, memory loss, behavioral disturbance, impaired problem-solving skills, and poor judgment. The patient was also at an increased risk of fall related injuries when left unattended. 

The appeal decision notice stated the prior denial was upheld. The previous request to increase hours from 98 per week to 168 hours was deemed not medically necessary. 

A letter reported the patient could benefit from increased in service hours due to worsening Alzheimer's dementia and congestive heart failure. It was noted the patient was wheelchair bound and also suffered from type 2 diabetes, hypertension, and right knee arthritis, decreasing the ability to perform activities of daily living. The patient also had urinary incontinence and required to be changed every 2 hours.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

Consumer Directed Personal Assistance Services (CDPAS) 24 hours per day, 7 days per week (split shift); a total of 168 hours per week is not considered medically necessary for this patient.

The request to increase personal assistant hours from 98 hours per week to 168 hours per week is not supported. There is a lack of documentation of significant change in clinical presentation to warrant increasing hours by 70 per week. There is a lack of documentation to support the need for significant care at night to warrant around-the-clock services. Based on the submitted assessments, 98 hours per week would address the patient's needs. Therefore, the request for 168 hours per week is not medically necessary, and the prior determination is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 
The medical necessity for Consumer Directed Personal Assistance Services (CDPAS) 24 hours per day, 7 days per week (split shift); a total of 168 hours per week is not substantiated.