Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Diabetes.

Treatment: Consumer Directed Personal Care Assistance Services (CDPAS) of 8 hours per day, 7 days per week for a total of 56 hours per week.

The insurer denied coverage for Consumer Directed Personal Care Assistance Services (CDPAS) of 8 hours per day, 7 days per week for a total of 56 hours per week.

The denial is overturned. 

This female patient has a medical history of dementia, diabetes mellitus, neuropathy, osteoarthritis, hypertension, incontinence, chronic pain, peripheral artery disease, glaucoma, hypertension, and gastroesophageal reflux disease. She currently has 4 hours per day of aide services. She needs assistance for toileting and incontinence care at various times during the other 20 hours of the day. The Uniform Assessment System (UAS) indicates the family provides assistance during non-aide hours, but the daughter is requesting additional Consumer Directed Personal Care Assistance Services (CDPAS) 4 hours per day, and so it appears that the family is not able to provide informal care during an 8 hour period of time each day. 

The patient needs caregiver assistance with all toileting and incontinence care at various and unscheduled times throughout the day and night. If there is a period of hours the patient has no caregiver assistance, she cannot properly and safely use the toilet or provide adequate hygiene and change of diapers. There are health and safety risks associated with lack of caregiver availability. The patient may try to use the toilet unassisted, which can result in falls. If she remains in soiled wet diaper several hours, this increases risk of skin damage. The patient has diabetes mellitus. Prevention of all types of skin damage is a priority, as diabetes increases the risk of complications from skin injury including infection and delayed wound healing.

The patient has multiple risk factors for falls, including arthritis, unsteady gait, incontinence, cognitive impairment, age, medications associated with fall risk. Patient education and/or physical therapy can be offered, but due to the patient's cognitive impairment, it is doubtful this would provide sustained improvement, as the patient's ability to follow instructions and retain information is limited. The patient attempts to walk without assistive devices. It is not uncommon for a person with dementia to forget to use an assistive device or forget how to use it properly. Having a caregiver present can ensure proper use of an assistive device and provide physical support. The patient needs a caregiver available throughout the day, as walking and transfers occur at unscheduled times. 

She is unable to cook or re-heat food; with services 4 hours per day, this does not cover all 3 meals. The patient has diabetes and the physician is concerned that she needs to be compliant with a diabetic diet to help control her glucose (which was recently high, 326). As per the physician, the patient's daughter works full time; the son-in-law's availability for assistance is limited (due to health problems). The physician is concerned about the patient not receiving an appropriate diet if there are insufficient hours of aide services to ensure proper food choices, preparation and service for all meals.

Considering the patient's medical history and functional impairment, it is medically necessary to have a caregiver present to provide assistance, including activities that occur at unscheduled times throughout the day.

When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services (in this case, CDPAS) are indicated to provide the patient with assistance for daily activities when necessary throughout the day. 
 
The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for the requested Consumer Directed Personal Care Assistance Services (CDPAS) of 8 hours per day, 7 days per week for a total of 56 hours per week is substantiated. The insurer's denial is reversed.