Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, osteoporosis, anxiety, insomnia, low back pain, and spinal stenosis
Treatment: Increase Consumer Directed Personal Assistance Services (CDPAS) to 24 Hours per Day, 7 Days per Week (Split Shift)
The insurer denied: Increase Consumer Directed Personal Assistance Services (CDPAS) to 24 Hours per Day, 7 Days per Week (Split Shift)
The denial is upheld.

The patient is an elderly male. His medical conditions include dementia, osteoporosis, anxiety, insomnia, low back pain, and spinal stenosis. The patient was discharged from rehab. Denial of increased consumer directed personal assistance services (CDPAS) to 24 hours per day, seven days per week (split shift) is being appealed. The health plan approved CDPAS (consumer directed personal assistance service) 24 hours/day, five days/week (split shift) and 24 hours/day, two days/week (live-in).
The patient's Uniform Assessment System (UAS) evaluation completed two months ago shows minimally impaired cognition, and functional status requires extensive assistance to total dependence with all activities of daily living (ADLs), except independent with eating. He is homebound and non-ambulatory. He uses a scooter and wheelchair for locomotion. He has frequent bladder incontinence. A letter from the patient's provider reports that the patient has dementia and needs assistance with all activities of daily living and 24-hour supervision for safety. A letter from another provider reports the patient has advanced Alzheimer's and requires total care with all activities of daily living.

The requested health service is not medically necessary. 

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, walking, transferring, turning/positioning, or feeding. 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 who 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 increased consumer directed personal assistance services (CDPAS) to 24 hours per day, seven days per week (split shift) is being appealed. The health plan approved CDPAS (consumer directed personal assistance service) 24 hours/day, five days/week (split shift) and 24 hours/day, two days/week (live-in). The health plan denied the increase in hours, because the patient does not need to eat or toilet every two hours, and overnight services would be for safety supervision. This patient has multiple conditions, including advanced dementia. Uniform Assessment System (UAS) evaluation completed two months ago shows he needs extensive assistance to except independent with eating. He is homebound and non-ambulatory. He has frequent bladder incontinence. Appeal statements report care is needed for all activities of daily living and safety supervision. Personal care services are not indicated for safety supervision or when no tasks are being performed. The information provided does not support that the patient has continuous nighttime needs that will prevent an aide from getting five hours daily of uninterrupted sleep during the aide's shift. The increase in CDPAS (consumer directed personal assistance service) to 24 hours per day, seven days per week (split shift) is not indicated.