Appeal type: Medical necessity
Decision: Upheld

Diagnosis: osteoarthritis, depression, diabetes and dementia

Treatment: consumer directed personal assistance program (CDPAP); 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - a total of 168 hours per week (split shift)

The insurer denied coverage for consumer directed personal assistance program (CDPAP); 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - a total of 168 hours per week (split shift)

The denial is upheld


This case involves an elderly male with a subject for review for the Denial of coverage for consumer directed personal assistance program (CDPAP); 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - a total of 168 hours per week (split shift).

A Uniform Assessment System (UAS) - New York Comprehensive Community Health Assessment was conducted and finalized. 

The patient was seen for memory loss and compulsive behavior. Magnetic resonance imaging (MRI) of the brain showed moderate diffuse atrophy. Electroencephalogram (EEG) done and showed slow background/diffuse slowing which is suggestive of a diffuse encephalopathy of metabolic, degenerative or vascular origin.

A Letter of Medical Necessity was submitted and stated that the patient has significant inability to move his upper and lower extremities and needs assistance throughout the day and night. Without the support, he will end up in a hospital or a nursing facility and his condition will deteriorate per the physician.

This patient with a diagnosis of osteoarthritis, depression, diabetes and dementia lives with his son, daughter-in-law, and 3 grandchildren in five-bedroom private house. Per daughter in law, patient is deaf and nonverbal and has dementia. Patient was unable to repeat any of the 3 words and was unable to state the procedure for making a sandwich as patient is nonverbal. As per patient's son the patient is unable to read or write. Patient's son reported that patient is unfamiliar with universal sign language, rather patient developed his own sign language which is how the family communicates with the patient. Patient currently has dementia which makes communicating a challenge.

The recent UAS notes the patient is totally dependent to maximal assistance for instrumental activities of daily living (IADLs) including  Meal preparation, Ordinary housework, Managing finances, Shopping, and Transportation and requires maximal assistance with Managing medication. These remain largely unchanged compared to the prior UAS. 

With regard to activities of daily living (ADLs), he is extensive assistance for bathing, personal hygiene  dressing upper and lower body- again essentially unchanged. Bed mobility is extensive assistance. He is occasionally incontinent of bladder and bowel -less than daily. There is a note  based on an office visit. The doctor notes memory issues and  obsessive compulsive disorder (OCD) where for example he spends hours in the bathroom (BR).  No functional data are provided. Also notes he is sometimes up in middle of the night. This is confirmed by the logs. Unfortunately, the details are mostly not discernable due to the logs submitted being mostly illegible due to poor photocopy. 

The data provided do not support need for 168 hours split shift. The approved hours 84 per week can be flexibly managed to best meet his needs. 

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 program (CDPAP); 12 hours per day - 7 days per week; 12 hours per day - 7 days per week - a total of 168 hours per week (split shift) services is not substantiated.