Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer Directed Personal Assistance services (CDPAS) - Split Shift 168 hours per week
The insurer denied coverage for Consumer Directed Personal Assistance services (CDPAS) - Split Shift 168 hours per week.
The denial is overturned.

This elderly patient has significant physical and cognitive impairment and needs substantial assistance with all daily activities. The patient lives alone in an apartment in a multifamily house. Her daughter lives on the upper level and provides some informal help; but the patient depends primarily on personal care services provided as Consumer Directed Personal Assistance Services (CDPAS). The patient is receiving CDPAS live-in services (91 hours per week). The patient (via designee) requested increase of CDPAS to 24 hours per day split shift, 168 hours per week, which was denied.

The most recent Uniform Assessment System (UAS) provided for review was done within the past year. The functional status report for instrumental activities of daily living (IADLs) indicates the patient is totally dependent for meal preparation, ordinary housework, managing finances, shopping, stairs; she needs maximal assistance for managing medications, phone use, transportation, and equipment management. For activities of daily living (ADLs), it was noted that the patient did not walk during the entire period, and she is totally dependent for locomotion (wheelchair, wheeled by others). She needs maximal assistance for bathing, personal hygiene, dressing upper/lower body, transfers to the toilet, toilet use; extensive assistance for eating; and limited assistance for bed mobility.

The patient has history of (h/o) dementia. The UAS description of the patient's cognition includes decision making for daily tasks is severely impaired - never/rarely makes decisions. The patient is disoriented to time and place; she has short term, procedural, and a situational memory problem. She is easily distracted. 

The patient has a history of behavioral problems and sleep disturbances associated with dementia. The daughter reported patient experiences sundowning with nighttime restlessness; hallucinations; resisting care at times (e.g., hygiene; refuses medications). 

The patient has h/o right above the knee amputation (years ago due to cancer).

Information supporting the need for 24-hour continuous (split shift) services includes the following: UAS reports the patient has frequent bladder incontinence; daughter reported bowel incontinence occurs at night; and the patient needs assistance with bed mobility. If the patient is not repositioned and does not have incontinence care for up to 5 hours (when live-in aide sleeps), the patient is at higher risk for incontinence associated skin damage, pressure ulcers, and urinary tract infection (UTI). Regarding falls, the patient has had frequent falls and remains at high risk for falls due to right above knee amputation (AKA) and her unawareness of the absence of her leg. Having an aide present in the patient's home, but unavailable to assist the patient for 8 hours per day (i.e., 5 uninterrupted hours of sleep, plus 3 other hours of sleep per day) is not a satisfactory plan. Other strategies may be considered for fall prevention, but at this time, 24-hour continuous services is medically necessary to help reduce occurrence of falls, as well as other medical complications noted above. CDPAS hours are flexible, but in this case, the patient needs an aide present and awake 24 hours per day, so 24 hour spilt shift services are necessary, either as CDPAS or standard personal care services. 

Based on the above, the insurer's denial must be overturned. The health care plan did not 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) - Split Shift 168 hours per week is substantiated.