Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other- Hemiparesis 
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 20 Hours per Day - Total of 140 Hours per Week, Continuous Care by More Than One Person 

The health plan denied: Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 20 Hours per Day - Total of 140 Hours per Week, Continuous Care by More Than One Person 
The determination is: Overturned. 


The patient is a female with a medical history notable for dementia, incontinence, history of falls, a prior cerebrovascular accident with hemiparesis, and coronary artery disease. The patient and her care team requested an increase to 20 hours per day of continuous care by more than one person, for a total of 140 hours per week.
The patient's physician provided a letter of support that states that the patient is severely limited in all physical activities and needs constant assistance. She also requires assistance with changing position in bed as often as every 20 to 30 minutes to avoid skin pressure, ulcers, and skin breakdown. She needs assistance with changing diapers after bowel movements. She requires hands-on assistance with all activities of daily living including ambulating, toileting, transfers, and bed mobility. Therefore, The physician requests continuous 24-hour care for the patient.
Another physician provided a letter of support. The letter states that since her cerebrovascular accident (CVA), the patient has suffered from memory decline, become more unsteady, and has had worsening weakness. Due to these factors, she needs assistance with all activities of daily living to prevent falls.
A uniform assessment system was completed and was available for review. The patient lives alone. She was alert and oriented, but noted to be forgetful at times. A mini mental state examination was performed and the score was 23 out of 30, consistent with mild cognitive impairment. For her instrumental activities of daily living, she requires total dependence for meal preparation, housework, finances, stairs, and transportation. She requires extensive assistance for medications. For her activities of daily living, she requires maximal assistance for bathing, dressing her lower body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing her upper body, and bed mobility.
Overnight caregiver logs were provided for review. They demonstrate that the patient requests assistance with turning and repositioning in bed every 30 to 60 minutes overnight. She also requires toileting approximately every 3 hours overnight. There were no significant overnight gaps in her personal care which would allow for a personal care aide to get sufficient rest.
At issue is the medical necessity of Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 20 Hours per Day - Total of 140 Hours per Week, Continuous Care by More Than One Person.

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

The requested health service of Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 20 Hours per Day - Total of 140 Hours per Week, Continuous Care by More Than One Person is medically necessary for this patient.
The patient has significant functional mobility as a result of her cerebrovascular accident and hemiparesis. She is unable to perform any activities of daily living without assistance. Furthermore, she suffers from incontinence. She requires frequent help throughout the day and also at night. Her personal care needs have been demonstrated to be continuous throughout the day and night. Furthermore, she has unscheduled personal care needs such as toileting and managing incontinence care. Therefore, the requested increase is medically necessary for the patient.