Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional impairment associated with various medical conditions.

Treatment: Consumer directed and self-directed personal assistance services of 24 hours a day, 7 days a week (split shift).

The insurer is denied coverage for consumer directed and self-directed personal assistance services of 24 hours a day, 7 days a week (split shift).

The denial is overturned.

This is a female patient who has a history of severe cervical cord spondylosis, lumbar spondylosis, and memory loss likely of a degenerative nature, osteoporosis, hypertension, hyperlipidemia, carotid atherosclerosis and gait disturbance. The patient has complaints of osteoarthritis pain in her shoulders, back and knees. She has limited range of motion to her upper extremities. The patient's son and niece are involved in her care and make decisions regarding her health and finances.

Based on the information provided for review, it is apparent that the patient is at risk for adverse health and safety events, including: falls and injury; skin damage due to inadequate incontinence care and/or inadequate pressure relief, inadequate pain management, nutritional decline. There are no detailed activity records of the patient's care needs throughout the day and night; but based on report of frequent incontinence and soaked diaper in the morning; the need for repositioning for pressure relief; need for pain management (including repositioning, and medication as needed); need for caregiver to assist with all aspects of food and fluid intake, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day and night. 

The patient has a supportive family, but the patient needs assistance beyond 52 hours per week, and it appears that there is insufficient informal caregiver assistance to meet the patient's daily care needs during non-Consumer Directed Personal Assistance Services (CDPAS) hours. The son reported that the family is paying privately for additional assistance, but this cannot be sustained on a long term basis. Considering the son is requesting CDPAS 24 hours per day split shift, it is reasonable to conclude that there are no informal caregivers who can provide care for extended periods of time each day/night; and privately hired aides do not appear to be a long term option. Therefore, personal care services (in this case CDPAS) are indicated to provide assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs) when needed throughout the day and night.

Based on the information provided for review, it is likely that the patient's need for assistance with daily activities during the day and at night (including nighttime ADLs) is too frequent for a live-in aide to consistently have 5 uninterrupted hours of sleep each day on a regular basis. Therefore, personal care continuous services/CDPAS (split shift) is indicated.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the requested consumer directed and self-directed personal assistance services of 24 hours a day, 7 days a week (split shift) is overturned. Medical necessity is substantiated.