Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic kidney disease, cognitive decline, coronary artery disease, hypertension, contain, fatigue, chronic pain, and weakness
Treatment: Increase in Consumer Directed Personal Assistance (CDPAS) to 7 days/week, 24 hours/day, continuous care by more than one person for a total of 168 hours/week
The insurer denied the increase in CDPAS to 7 days/week, 24 hours/day, continuous care by more than one person for a total of 168 hours/week.
The denial is overturned.

The patient is an elderly female. Her conditions include chronic kidney disease, cognitive decline, coronary artery disease, hypertension, contain, fatigue, chronic pain, and weakness. She lives alone. Denial of increase in consumer directed personal assistance (CDPAS) from 7 days/week, 8 hours/day to 7 days/week, 24 hours/day, continuous care by more than one person for a total of 168 hours/week is being appealed.

The patient's Uniform Assessment System (UAS) evaluation completed recently shows minimally impaired cognition and functional status: total dependence with housework, shopping; maximal assistance with meal preparation, managing finances and medications, bathing, lower body dressing, and toilet use; extensive assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, toilet tanner, and bed mobility; and limited assistance with eating. She has bowel and bladder incontinence.

An appeal statement notes that the patient requires assistance with ADLs (activities of daily living). She needs assistance with transferring, turning/repositioning every two hours throughout the night, walking, bathing, and toileting.

A letter from the patient's provider notes the patient needs assistance with all ADLs and repositioning thought the night.

The requested health service is medically necessary. 

Personal care service (PCS) is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift PCS is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase in CDPAS from 7 days/week, 8 hours/day to 7 days/week, 24 hours/day, continuous care by more than one person for a total of 168 hours/week is being appealed. The health plan noted that PCS is not authorized when the need for assistance can be met with adaptive equipment.

This patient has multiple chronic conditions. UAS evaluation completed recently shows the patient requires assistance with all ADLs. She is incontinent of bowel and bladder. Appeal statements support the need for assistance with all ADLs and note that the patient needs turning/repositioning every two to three hours during nighttime. This patient has continuous needs, including frequent turning/repositioning that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved CDPAS 7 days/week, 8 hours/day is insufficient to meet the patient's needs for assistance with ADLs and personal care. The requested CDPAS 7 days/week, 24 hours/day, continuous care by more than one person for a total of 
168 hours/week is medically necessary.