Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer personal assistance program (CDPAP) 8 hours (hrs) per day, 7 days per week - for a total of 56 hrs per week.
The insurer denied Consumer personal assistance program (CDPAP) 8 hours (hrs) per day, 7 days per week - for a total of 56 hrs per week.
The determination is upheld.

This is a female patient with a medical history notable for dementia. The patient is approved for 4 hours per day, 4 days per week for a total of 16 hours per week of consumer directed personal care assistance. The patient and her care team requested an increase to 8 hours per day, 7 days per week for a total of 56 hours per week, and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has profound dementia, major depressive disorder, and history of multiple lacunar strokes. She is unable to care for herself and requires assistance with all aspects for activities of daily living including ambulation, feeding, bathing, dressing, cooking, shopping, and transportation. The physician feels that 16 hours per week is inadequate for her level of impairment. They recommend the requested increase in order to care for her personal care needs.
A Uniform Assessment System (UAS) was completed. The assessment states that the patient lives with her husband, daughter, son-in-law, and two grandchildren and a private home. The patient was alert and oriented to person and place only. She is not able to direct her own care. Short-term memory was zero out of three at five minutes. Procedural memory was not intact. It was noted that she is not safe to be left alone. That patient requires contact assistance with transfers and toileting, as well as assistance with cleaning herself after toilet use to ensure safe balance and proper cleaning. She is frequently incontinent of urine and his continent of stool. She wears liners and Pull-Ups for incontinence care. She does not have any issues with night time incontinence.  A task tool associated with the assessment recommended 5.5 hours per day, 4 days per week for a total of 22 hours per week to adjust the patient's personal care needs. Compared to a prior assessment, the patient showed a decline in functional status. At issue is the medical necessity of consumer personal assistance program (CDPAP) 8 hours (hrs) per day, 7 days per week - for a total of 56 hrs per week.

The requested health service of Consumer personal assistance program (CDPAP) 8 hrs per day, 7 days per week - for a total of 56 hrs per week is medically necessary for this patient.
The patient has advanced dementia which has resulted in functional deficits across all aspects of personal care. She requires personal care assistance with ambulation, transfers, toileting, and incontinence care. Her personal care needs can be expected to be continuous and unscheduled throughout the day. As documented by the physician and the patient's daughter, her current allotment of personal care hours is insufficient to meet her personal care needs. Therefore, the requested increase is medically necessary and reasonable for the patient. Failure to address the patient's personal care needs could result in infection, skin breakdown, and or injury.