Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease

Treatment: Consumer Directed Personal Assistance Services (CDPAS), 16 hours a day (split-shift), 7 days a week, for a total of 112 hours a week.

The insurer denied the Consumer Directed Personal Assistance Services (CDPAS), 16 hours a day (split-shift), 7 days a week, for a total of 112 hours a week.

The denial was reversed.

This patient is an elderly female with a history of Alzheimer's dementia with cognitive impairment, behavioral disturbance, bilateral hearing loss, urinary incontinence, constipation, bradycardia. It was reported that the patient lives in an apartment alone. She has poor judgment, very limited insight, and poor memory. She is dependent on assistance from others for IADLs and ADLs. The current level of care, 12 hours/7 days does not meet the patient's needs. Her son (primary caregiver) needs more assistance. It is strongly recommended that home health aide hours are increased to 16 hours/7 days a week.

For IADLs, the patient needs extensive or maximal assistance, or total dependence for all tasks. For ADLs, she needs limited or extensive assistance. The UAS was completed over 6 months ago, and based on the letter from one of her children it appears the patient may currently need more than limited assistance for walking and toileting. The letter indicates the patient's gait has deteriorated significantly. She needs assistance for toileting. She is often incontinent and does not inform the caregiver when incontinence occurs. 

The patient has physical difficulty with transfers and walking and has severely impaired judgment and safety awareness; therefore she needs assistance to safely and properly perform these mobility-related ADLs. The patient is disoriented to time and place, and her thought processes are impaired; and so she may attempt to stand and walk at any time for reasons real or imagined. It is necessary for a caregiver to be present during the day and night for assistance with transfers and ambulation. 

The patient needs assistance for all aspects of toileting including transfer on/off the toilet, hygiene, adjustment of clothes. The patient is frequently incontinent and needs caregiver assistance for incontinence care (instructions were provided to caregivers by UAS nurse). 

The patient is currently approved for CDPAS 12 hours per day, 7 days per week. The family (via patient advocate) requested additional 4 hours per day. The letter from the family indicated that the additional services are intended for the hours of 4-8pm, i.e. dinner, and evening ADLs prior to going to bed. The family is asking for 4 additional CDPAS hours per day; and so it is reasonable to conclude that informal caregivers are unable to provide assistance to the patient on a consistent basis for those additional 4 hours per day. Therefore, personal care services (in this case CDPAS) are indicated to provide the additional hours of assistance the patient needs for ADLs and IADLs.

Consumer Directed Personal Assistance Services (CDPAS), 16 hours per day (split shift), 7 days per week, total of 112 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Consumer Directed Personal Assistance Services (CDPAS), 16 hours a day (split-shift), 7 days a week, for a total of 112 hours a week is substantiated.  The insurer's denial is reversed.