Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Incontinence/Urinary/Bladder Control.
Treatment:  Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift).
The insurer denied CDPAP Services - 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift).  
The health plan's determination is upheld.

The patient is a female with a past medical history of morbid obesity, schizophrenia, panic disorder with agoraphobia, depression, gastroesophageal reflux disease (GERD), lymphedema of bilateral lower extremities, urinary incontinence, osteoarthritis, and asthma who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 8 hours/day, 7 days/week, to total 56 hours/week based on assessment performed via video on assessing the patient at total assistance with tasks of ordinary housework, stairs, bathing, and dressing lower body while maximum assistance with tasks of meal preparation, managing medication, shopping, personal hygiene, dressing upper body, transfer toilet, toilet use, and bed mobility.  With the task of managing finances, the patient was assessed at limited assistance, supervision with task of phone use, and independent with task of eating. Notes from the video assessment stated the patient lived with her father and had a decline in activities of daily living (ADL) status, as well as a deterioration in overall self-sufficiency in the last 90 days. In addition, notes stated the patient had frequent incontinence of urine and bowel.

The patient had another video assessment assessing the patient at total assistance with tasks of ordinary housework, stairs, transportation, bathing, and dressing upper body while maximum assistance with tasks of meal preparation, managing medication, shopping, personal hygiene, dressing upper body, transfer toilet, toilet use, and bed mobility. The patient was assessed at limited assistance with task of managing finances, supervision with task of phone use, and independent with task of eating. Notes from the assessment stated the patient was bedbound and had a deterioration in overall self-sufficiency. 

At issue is the medical necessity of the requested health service/treatment of Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift).

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) is not medically necessary for this patient.

Although there is documentation of the patient's unpredictable and unscheduled care needs, there is no documentation of the specific timing of these care needs in the overnight hours that would not allow a CDPAP at least 5 hours of uninterrupted sleep. There is no documentation of overnight care logs. In addition, there was no documentation of medical necessity of turning and repositioning at least every 2-3 hours overnight. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) are not medically necessary for this patient.