Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's Dementia.
Treatment: Consumer Directed Personal Assistance Program (CDPAP) 12 hours per day - 7 days per week; 12 hours per day - 7 days per week for a total of 168 hours per week (split shift).

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP) 12 hours per day - 7 days per week; 12 hours per day - 7 days per week for a total of 168 hours per week (split shift). The denial is upheld.

This patient is an elderly patient with chronic medical problems, including Alzheimer's dementia. The patient lives with their daughter in a 1-bedroom apartment. However, the Uniform Assessment System (UAS) report also indicates, "During the day, member spends their time at their daughter's house, which is a 3-bedroom 2 story private home with 5 steps to walk up to the entrance of the house."  In addition, the patient "is never left alone."  The patient is receiving the Consumer Directed Personal Assistance Program (CDPAP) 7 days per week, 12 hours per day, for 84 hours per week. The request is for the Consumer Directed Personal Assistance Program (CDPAP) 12 hours per day - 7 days per week, 12 hours per day - 7 days per week for a total of 168 hours per week (split shift), leading to an external review.   

The UAS report was reviewed. The patient's cognition is described as severely impaired. The patient is reportedly totally dependent on completing much of their Instrumental Activities of Living (IADL) tasks, including meal preparation, ordinary housework, and shopping. The patient reportedly requires maximal assistance for bathing, personal hygiene, dressing, eating, and toilet use. Extensive assistance is reportedly needed for bed mobility, locomotion, toilet transfer, and ambulation. The patient is reportedly incontinent of bladder and bowel.  

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the requested CDPAP services 7 days per week, 24 hours per day (split shift). The patient's ability to perform activities of daily living (ADLs), self-sufficiency, or reported falls over the prior 90 days has remained the same. The patient's cognitive and functional status is also much the same as the previous UAS report. The request for increasing personal care hours is reportedly due to the patient not being safe at night and their tendency to wander and fall risk. The reviewer would agree the patient may benefit from additional monitoring for safety, mainly due to their cognitive status, wandering, and fall risk. However, CDPAP hours are approved primarily to provide hands-on assistance for completing IADL/ADL tasks when no one else can assist. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the insurer-approved CDPAP 7 days per week, 12 hours per day, for a total of 84 hours per week.

From a physical medicine and rehabilitation perspective, an increase in Consumer Directed Personal Assistance Program (CDPAP) 12 hours per day- 7 days per week; 12 hours per day- 7 days per week for 168 hours per week (split shift) is not medically necessary.  

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the patient's best interest. 

The medical necessity for the Consumer Directed Personal Assistance Program (CDPAP) 12 hours per day- 7 days per week; 12 hours per day - 7 days per week for 168 hours per week (split shift) is not substantiated.