Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Consumer Directed Personal  Assistance Program (CDPAP) Services 12 Hours Per Day -7 Day(s) Per Week (split shift) A  Total of 168 Hours Per Week
The insurer denied the Increase Consumer Directed Personal  Assistance Program (CDPAP) Services 12 Hours Per Day -7 Day(s) Per Week (split shift) A  Total of 168 Hours Per Week
The denial is overturned

The patient is a female with dementia. She is unable to walk due to fatigue and weakness. Her daughter is appealing denial of increase to CDPAP (Consumer Directed Personal Assistance Program) at 12 hours per day for a total of 168 hours per week. She has been approved for 56 hours week.

The patient's daughter states that the patient needs constant care. The patient lives in an assisted living facility and has a 24-hour private hire personal care aide. Her daughter is supportive and involved in her care. Assessment performed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, phone use, lower body dressing, locomotion, and toilet use; maximal assistance with bathing, upper body dressing, and eating; and extensive assistance with personal hygiene, and bed mobility. She is incontinent of bowel and bladder. Her equipment includes a wheelchair, hospital bed, shower chair, shower grab bar, pull ups, and under pads.

An advocacy appeal letter states that the patient needs overnight functional assistance, because she is dependent on all ADLs (activities of daily living), bed bound, requires repositioning, and is unable to summon help. Physician's order notes she has conditions including dementia, depression, anxiety, hypertension, GERD (gastroesophageal reflux disease), insomnia and bedridden. States she needs assistance with all ADLs (activities of daily living), wound care twice daily, turning and repositioning.

A letter notes the patient needs continuous assistance with all ADLs (activities of daily living).

Yes, the Increase Consumer Directed Personal  Assistance Program (CDPAP) Services to 12 Hours Per Day -7 Day(s) Per Week (split shift), for a total of 168 Hours Per Week is medically necessary. Medically necessary services are those which are

-	Safe
-	Effective
-	Generally accepted national standard of medical practice
-	Not provided primarily for convenience of the patient or the practitioner
-	The least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary, because it is consistent with generally accepted national standard of medical practice.

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient has dementia and has limited mobility, making her bedbound. This patient requires assistance with all ADLs (activities of daily living) and personal care needs.  Assessment performed shows the patient requires extensive assistance to total dependence with all ADLs/IADLs (activities of daily living/instrumental activities of daily living).  The appeal statement from her doctor adds that the patient needs assistance with turning and repositioning. She is incontinent and needs unscheduled assistance toileting and diaper changes.  This patient requires significant assistance with ADLs (activities of daily living) and has continuous needs that cannot be met with the approved CDPAP (consumer directed personal assistance program) at 56 hours per week.  Based on this patient's dementia and physical limitations, the proposed increase to 168 hours per week is medically necessary to meet this patient's needs for assistance as noted above.