Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Consumer Direct Personal Aide Service (CDPAS): 7 Days per Week, 12 Hours per Day (Total of 84 Hours per Week).
The insurer denied Consumer Direct Personal Aide Service (CDPAS): 7 Days per Week, 12 Hours per Day (Total of 84 Hours per Week).
The determination is overturned.


This is a male patient with a past medical history of hypertension, diabetes mellitus type 2, gastroesophageal reflux disease (GERD), benign prostatic hyperplasia (BPH) with elevated prostate-specific antigen (PSA), hyperlipidemia, glaucoma, dementia, constipation, chronic anticoagulation, and urinary incontinence who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 6 hours per day, 7 days/week to total 42 hours/week. The patient was in a motor vehicle accident (MVA) with a fractured right foot and abdominal surgery and reported worsening dementia. His daughter moved in with him.
An office visit stated the patient had worsening dementia with increased agitation and incontinence and medications were adjusted. The provider recommended at least 10 hours of personal care services per day. With this request to increase CDPAP services, the patient underwent a video assessment. The insurer partially denied approval of increase in CDPAP services approving 8 hours/day, 7 days/week, to total 56 hours/week.
The insurer sent a final adverse determination denial notice continuing to partially deny the requested increase in CDPAP services stating the patient must have a documented significant change in functional status requiring additional time and assistance to complete his instrumental activities of daily living. In addition, the denial stated upon secondary review of the patient's clinical record including but not limited to a sleep study when applicable, the criteria had been partially approved as there were documented changes that had taken an effect to the patient's environmental surroundings, social setting, and/or functional abilities such as bathing, dressing, and toileting. 
At issue is the medical necessity of Consumer Direct Personal Aide Service (CDPAS): 7 Days per Week, 12 Hours per Day (Total of 84 Hours per Week).
The requested services are medically necessary. 
There is documentation from the patient's medical provider of worsening cognitive status and functional decline. The video-based assessment underestimated the patient's care needs for assistance with Instrumental activities of daily living (IADLs) and activities of daily living (ADLs). The patient now has urinary and fecal incontinence. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, CDPAP services 7 Days per Week, 12 Hours per Day (Total of 84 Hours per 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.