Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer directed personal assistance program (CDPAP)- 12 hours per day, 7 days per week (split shift); total of 168 hours per week
The insurer denied consumer directed personal assistance program (CDPAP)- 12 hours per day, 7 days per week (split shift); total of 168 hours per week.
The determination is overturned.

The patient has a past medical history of a cerebrovascular accident (CVA) with dysphagia, congestive heart failure, diabetes mellitus (DM) type 2, vascular dementia, left foot ulceration with osteomyelitis, peripheral artery disease, legal blindness, gout, chronic renal failure, hypertension, urinary incontinence and constipation and had been assigned 6.5 hours/day, 7 days/week to total 45.5 hours/week. The patient's neurologist provided a letter stating the patient had a stroke and experiencing impairment related to dementia with progression of his personal care needs. The letter stated the patient requires assistance in all activities of daily living (ADLs) as well as supervision to prevent falls and wandering. It was recommended the patient have additional four hours a day of personal care assistant (PCA) service needs. The patient had a telephonic assessment tool performed with total assistance with tasks of meal preparation, ordinary housework, managing finances, shopping and locomotion while maximum assistance with tasks of managing medication, phone use, stairs and transportation. The patient was assessed at extensive assistance with tasks of bathing, personal hygiene, dressing upper/lower body, walking, transfer toilet, toilet use, bed mobility and eating. The patient's surgeon provided a letter stating the patient has left lower extremity ulceration of the ankle and foot with gangrenous changes with need for more home care and support with high risk of amputation which would cause progression of his symptoms and need for further increased home care. The patient had a large ulcer of the left heel with osteomyelitis and the patient was placed on hospice care.
Notes from hospice stated the patient was total dependence for bathing, dressing and feeding and was without capacity. The patient had 2 liters of oxygen and was totally bedbound and unable to do any activity. The hospice provider's letter stated that the patient had chronic severe pain related to his left heel osteomyelitis. The letter stated the patient is unable to bear weight on legs, needs full hands-on assistance to lift body to come out of bed, stand, take steps to wheelchair, transfer from wheelchair to toilet, complete toilet hygiene, shower, support body weight to transfer from wheelchair to table for meals. The letter stated the patient needed contact guard at all times, daily bed baths (day and overnight diaper change), cleaning and dressing of left heal wound with osteomyelitis, can no longer toilet, dress, bathe or eat independently. This letter from the hospice provider further stated patient had a complex medication regimen that required scheduled administration times and requires twenty four hour assistance.
The patient's primary care physician (PCP) provided a letter stating the patient's medical conditions and to ensure his safety and quality of life, the patient requires around the clock assistance of certified home health aides, 7 days per week. The patient had a telemedicine visit with the PCP stating the patient was living at home with his family and has hospice for PAD with ongoing foot pain. The office note further stated the patient needs help with dressing, bathing, toileting, transferring and eating. In addition, the office note states the patient needs 24 hour assistance at home because of his advanced disease and comorbidities and need for assistance with all ADLs. There is a log of activity for patient provided which was undated documenting the need to turn patient and change diaper every two hours over the nighttime hours. The insurer provided final adverse determination denial letter stating some of the patient's abilities to perform daily activities stayed the same and some declined and assigned 9 hours of PCA/ Consumer Directed Personal Assistance Services (CDPAS) service hours, 7 days/week to total 63 hours/week. The letter stated additional hours are not granted when tasks are not being performed and for safety monitoring and supervision and therefore increasing CDPAS hours is not medically necessary. Notes from a hospice meeting stated the patient was total care, fed two meals per day, and had worsening left foot wound. At issue is the medical necessity of consumer directed personal assistance program (CDPAP)- 12 hours per day, 7 days per week (split shift); total of 168 hours per week medically necessary for this patient.
Question(s):
The services are medically necessary. The patient had peripheral artery disease and nonhealing left heel ulcer with resultant osteomyelitis which was not healing. The patient had progressive worsening in his ability to perform ADLs and Instrumental activities of daily living (IADLs) because of this. A decision was made to place patient on hospice with further decline in his functional status as noted by PCA/CDPAS care needs log. The telephonic assessment noted the patient had a significant change in status. The telephonic assessment noted the patient to be severely impaired cognitively with a decline in ADL status and deterioration of self sufficiency. The assessment underestimated the patient's PCA/CDPAS assistance needs for managing medication, bathing, personal hygiene, dressing upper body, transfer toilet, toilet use, bed mobility and eating. The patient has unscheduled and unpredictable care needs over a particular span of time and therefore the Uniform Assessment System (UAS) tool should not be used to assess PCA/CDPAS service hours. The plan did not document whether the patient's needed assistance can be scheduled or occurs at unpredictable times day and night and the plan must assure that the plan of care can meet any unscheduled or recurring daytime and nighttime needs that the patient has for assistance. The PCA/CDPAS care needs were documented in log, noting at assistance needs with turning patient, changing diapers and repositioning left foot every two hours. The patient's PCA/CDPAS services are not solely for supervision and safety but to assist the patient with specific tasks of personal hygiene, toilet use and incontinence cares, turning and repositioning and eating. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home. The patient needs to have assistance with turning, repositioning, incontinence cares and drinking and eating throughout the day and night in order to prevent further suffering and illness due to pain and/or skin breakdown or infection.