Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia, osteoarthritis, muscle weakness and conductive bearing loss.
Treatment:  Consumer Directed Personal Aide Services (CDPAS) 7 days x 12 hours x 2 shifts.

The insurer denied coverage for Consumer Directed Personal Aide Services (CDPAS) 7 days x 12 hours x 2 shifts.  The denial is overturned.
 
This elderly female has extensive functional impairment and needs assistance with all daily activities. As per the Uniform Assessment System (UAS), the patient lives alone. Her son provides some informal help, but the patient primarily relies on personal care services, provided as Consumer Direct Personal Aide Service (CDPAS).  She receives CDPAS 12 hours per day, 7 days per week; total of 84 hours per week. The patient's son (as patient designee) requested an increase of services to two 12 hour shifts per day, 7 days per week; total of 168 hours per week, which was denied.

The most recent UAS provided was reviewed. Functional status for instrumental activities of daily living (IADLs) indicates the patient was totally dependent for meal preparation, ordinary housework, managing finances, shopping, phone use; she needed maximal assistance for managing medications; extensive assistance for transportation, stairs. For activities of daily living (ADLs), it was noted the patient did not walk during entire period; total dependence for locomotion (wheelchair), transfer toilet; maximal assistance for bathing, dressing lower body, toilet use; extensive assistance for personal hygiene, dressing upper body, bed mobility, eating.

Comparison with the prior UAS  indicates decline for a few ADLs (prior UAS is noted first; more recent UAS is in parentheses): Walking: maximal assistance (did not occur entire period); toilet transfer: maximal assistance (total dependence); bed mobility and eating: limited assistance (extensive assistance).

Regarding the patient's cognition, the UAS includes diagnosis of dementia. There is no formal evaluation of cognition available for review, the more recent UAS provides some information. Decision making for daily tasks was described as moderately impaired - decisions consistently poor or unsafe, cues/supervision needed at all times. The patient's son directs care. The patient was oriented x 1; she had short term and procedural memory problem. It was noted that mental function varies over the course of the day. She is easily distracted; and has episodes of disorganized speech. Her communication ability was limited to concrete requests; she responds only to simple, direct communication (patient did not respond to questions during UAS, e.g., regarding mood, anxiety). No behavioral problems were reported.

The patient's functional impairment can have significant adverse consequences if she does not have sufficient help with daily activities.

Based on the information provided for review, it is medically necessary, and in the patient's best interest to have a caregiver 24 hours per day, present and awake to provide care when needed. 

The records provided for review support the patient's need for 24-hour continuous services (split shift).

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Consumer Directed Personal Aide Services (CDPAS) 7 days x 12 hours x 2 shifts is substantiated.