Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia, Parkinson's Disease
Treatment Consumer Directed Personal Assistant Services (CDPAS): 7 Days x 24 Hours (Continuous Services) per Week
The insurer denied Consumer Directed Personal Assistant Services (CDPAS): 7 Days x 24 Hours (Continuous Services) per Week
The determination is overturned.

The patient has a past medical history of vascular dementia, Parkinson's disease, gastroesophageal reflux disease (GERD), hypertension, bladder incontinence, bowel incontinence, benign prostatic hyperplasia (BPH), permanent pacemaker (PPM), macular degeneration, and bipolar disorder whose primary care physician (PCP) had filled out Department of Health (DOH) 4359 physician order for personal care assistant (PCA) services noting that the patient cannot walk at all and needs 24 hours/day, 7 days/week care/supervision. The patient's neurologist provided a letter  stating the patient has postural gait instability with shuffled gait, has dementia and is unable to provide his own medical history, recommended a specialized walker, and was diagnosed with Parkinson's disease. The patient underwent a telephonic universal assessment. The patient's PCP provided another Department of Health (DOH) 4359 form stating the patient cannot do any of his own activities of daily living (ADLs), his daughter works full time, and the patient has no other local support. The patient had another telephonic assessment assessing the patient at maximum assistance with tasks meal preparation, ordinary housework, and managing medication and extensive assistance with tasks of bathing, dressing, and locomotion. The patient had another assessment tool performed assessing the patient at total assistance with tasks of ordinary housework and managing finances while maximum assistance with tasks of meal preparation, managing medication, phone use, stairs, shopping, and transportation. The patient was assessed at extensive assistance with tasks of bathing, dressing upper/lower body, transfer toilet and toilet use while limited assistance with tasks of personal hygiene, walking, locomotion and bed mobility.
The insurer sent an initial adverse determination denial notice stating the patient no longer met criteria for  Consumer Directed Personal Assistance Services (CDPAS) services at 24 hour/day, split-shift, 7 days/week to total 168 hours/week and services were being decreased to 9 hours/day, 7 days/week to total 63 hours/week. Subsequently, the insurer sent a final adverse determination denial notice stating the reduction in CDPAS hours to 63 hours/week stating services were not authorized for safety monitoring, some of the patient's CDPAS needs can be met with specialized equipment or adaptive devices, and that the patient had been referred to the nursing home transition and diversion waiver program. Overnight care logs were provided for review noting the patient required assistance to the bathroom 4-5 times in the overnight hours and assisted to the kitchen once in the overnight hours. The patient's PCP provided another DOH 4349 form stating the patient has end stage Parkinson's disease, does not meet hospice criteria, cannot administer medications, cannot walk alone, and needs to be fed. The patient's neurologist provided a letter stating the patient is in need of increased structured supervision and support in order to meet his basic daily needs. The letter further stated the patient is unable to meet his activities of daily living, requires prompting to complete all ADLs, requires medication reminders and administration assistance, has terminal dementia that has not improved since the last review with anticipated continued decline, and the patient needs around the clock supervision and cannot be left alone for a second. The patient's health care advocate provided a letter requesting and an expedited appeal of denial decision. The letter also noted the plan did not address a specific medical circumstance that justified reduction in CDPAS services and that overnight functional needs were not for safety and supervision. In addition, the letter stated the patient has not improved since his last evaluation and is not expected to improve according to his medical providers given his medical diagnoses. At issue is the medical necessity of Consumer Directed Personal Assistant Services (CDPAS): 7 Days x 24 Hours (Continuous Services) per week.

The requested services of Consumer Directed Personal Assistant Services (CDPAS): 7 Days x 24 Hours (Continuous Services) per week are medically necessary.
The patient has medical diagnoses of Parkinson's disease, dementia, BPH, bladder incontinence, and bowel incontinence. There is documentation of worsening of the patient's Parkinson's disease and dementia. The patient had previously been assigned 24 hours/day, continuous, 7 days/week of CDPAS services and the patient's condition had not improved at the assessments compared to previous assessments. The insurer did not document a plan which would meet the patient's unplanned and unscheduled care needs such as walking, locomotion, bed mobility, transfer toilet, toilet use and personal hygiene activities which would all be necessary for use of the bathroom for urination and bowel movements. The universal assessment tool should not have been utilized to assign CDPAS hours as the patient has established 24 hour care needs. The patient's overnight logs document the patient's care needs that would not allow a CDPAS to obtain five hours of uninterrupted sleep. The increase/retainment of CDPAS hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/ Instrumental activities of daily living (IADLs)s. 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, CDPAS services 24 hours/day, continuous, 7days/week, to total 168 hours/week are medically necessary for this patient. 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 health plan's determination is overturned.