Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia  
Treatment: Consumer Directed Personal Assistance Services (CDPAS), 24 hours per day, Split Shift  

The insurer denied the Consumer Directed Personal Assistance Services (CDPAS), 24 hours per day, Split Shift. The denial was reversed.   

This is a female patient with a medical history of dementia with behavioral disturbance, diabetes mellitus (DM) type 2, hyperlipidemia, hypertension, transient ischemic attack (TIA) and cerebral infarction, peripheral neuropathy, asthma, GERD, panic disorder, depression, osteoarthritis, osteoporosis, history of falling, gait abnormality, insomnia, stress incontinence, hearing loss, cataract, and mental and cognitive disorders. She is currently receiving Consumer Directed Personal Assistance Services (CDPAS) 12 hours per day (84 hours per week). Her most recent UAS indicated that the patient requires high level of assistance for all activities of daily living (ADLs) with the exception of eating. The family is requesting an increase in her coverage to 24 hours per day, split shift.  

The insurer has recognized the patient's need for assistance by approving personal care services for 12 hours per day.  The patient needs assistance with transfers, walking and toileting.  These activities are not limited to 12 hours per day.  As people get older, nighttime toileting needs often increase in frequency, and are usually unscheduled.  For a person with dementia, nighttime behavior can be unpredictable.  The patient's son reports the patient is frequently awake at night.  It is likely she needs to use the bathroom at some point, and/or may have other needs (real or imagined) that motivate her to try to get out of bed.  The patient needs extensive (weight-bearing) assistance to transfer, walk and use the toilet.  Therefore, the need for a caregiver to be present at night is not for safety supervision, but to provide assistance with ADLs when the patient needs to get out of bed, walk and use the toilet.  

The patient is at risk for and has history of falls.  Falls in the elderly can have critical consequences.  When older people fall, there is a higher risk of serious injuries (e.g. fractures, head trauma), substantial morbidity, and increased risk of death.  The patient already has h/o falls, so this is not a hypothetical situation.  Fall prevention needs to be a priority of the patient's care plan.  Some interventions may be useful, e.g. physical therapy; but due to patient's cognitive impairment, it is uncertain whether physical therapy can produce a sustainable improvement of function.  At this point, the patient needs assistance to safely perform all mobility related ADLs when they occur at all times of the day and night.  

The patient has multiple medical conditions that have resulted in substantial functional impairment for all daily activities, including ADLs that occur at unscheduled and unpredictable times throughout the day and night.  It is medically necessary for the patient to have assistance with ADLs during day and nighttime hours; and therefore, personal care services (in this case CDPAS) are indicated to provide the necessary assistance.  

Consumer Directed Personal Assistance Services, 24 hours per day, split shift, is medically necessary.  

The health plan did not act reasonably, with sound medical judgment in the best interest of the patient.  
 
Based on the above, the medical necessity for Consumer Directed Personal Assistance Services (CDPAS), 24 hours per day, Split Shift, is substantiated.  The insurer's denial is reversed.