Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic pancreatic cancer, kidney failure, diabetes, and coronary artery disease
Treatment: Increase Consumer Directed Personal Assistant Program (CDPAP) to 12 hours per day - seven days per week; 12 hours per day - seven days per week; Split Shift; for a Total of 168 Hours Per Week
The insurer denied: Increase Consumer Directed Personal Assistant Program (CDPAP) to 12 hours per day - seven days per week; 12 hours per day - seven days per week; Split Shift; for a Total of 168 Hours Per Week
The denial is overturned.

The patient is an elderly male. His medical conditions include metastatic pancreatic cancer, kidney failure, diabetes, and coronary artery disease. He is enrolled in hospice. Denial of increase consumer directed personal assistant program (CDPAP) to 12 hours per day - seven days per week; 12 hours per day - seven days per week; split shift; for a total of 168 hours per week, is being appealed. The health plan approved 12 Hours/Day - 7 day(s) per week - 84 hours per week. Uniform Assessment System (UAS) evaluation performed this year shows moderately impaired condition and functional status: total dependence with meal preparation, housework, managing finances and medications, shopping, transportation, and locomotion; maximal assistance with bathing, personal hygiene, dressing, toileting, and bed mobility; and extensive assistance with phone use and eating.

An appeal statement from the hospice director notes the patient has declined and is bedbound and dependent with all care. Split shift care is requested for turning and repositioning every 2 hours.

The requested Increase Consumer Directed Personal Assistant Program (CDPAP) to 12 hours per day - seven days per week; 12 hours per day - seven days per week; Split Shift; for a Total of 168 Hours Per Week is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase consumer directed personal assistant program (CDPAP) to 12 hours per day - seven days per week; 12 hours per day - seven days per week; split shift; for a total of 168 hours per week, is being appealed. The health plan approved 12 
Hours/Day - 7 day(s) per week - 84 hours per week. The health plan denied coverage of the increase in care because most of the patient's abilities to perform daily activities stayed the same between UAS (Uniform Assessment System) assessments from this year and last year, and his needs can continue to be met safely with current CDPAP (consumer directed personal assistant program) hours of 84 hours per week. Granting additional hours are not provided when tasks are not being performed and for safety monitoring and supervision.

This patient has multiple chronic conditions, including metastatic pancreatic cancer. Uniform Assessment System (UAS) evaluation completed this year showed the patient requires extensive assistance to total dependence with all ADLs (activities of daily living). An appeal statement from the hospice provider notes the patient needs turning and repositioning every 2 hours.

The appeal statements support the patient is dependent with all ADLs (activities of daily living) and requires frequent assistance with turning/repositioning. The approved CDPAP (consumer directed personal assistance program) 84 hours per week is insufficient to meet this patient's needs. The requested CDPAP (consumer directed personal assistance program) services for a total of 168 hours per week, split shift is medically necessary.