Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment:  Increase Personal Care Aide (PCA) and Consumer Directed Personal. Assistance Program (CDPAP) Services for A Total of 168 Hour(s) Per Week.
The insurer denied the  Increase Personal Care Aide (PCA) and Consumer Directed Personal Assistance Program (CDPAP) Services for A Total of 168 Hour(s) Per Week.
The denial is overturned.

This male has conditions including severe dementia and osteoarthritis. He lives alone. He is appealing denial of increase personal care aide (PCA) and consumer directed personal assistance program (CDPAP) services for a total of 168 hours per week. The plan approved personal care aide and consumer directed personal assistance program live-in per diem 7 days per week. Uniform Assessment System (UAS) evaluation completed previously shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medication, bathing, personal hygiene, dressing, locomotion, toileting, and eating; and maximal assistance with phone use and bed mobility. Compared to uniform assessment system evaluation completed most recently, there has been a decline with upper body dressing and personal hygiene. He has bowel and bladder incontinence. He is wheelchair bound.	
Appeal letters note there has been a decline in the member's cognitive and physical functioning. A statement from New York State notes the member cannot sleep through the night and requires medication management and toileting overnight. Notes the member wanders when left alone. His son-in-law has been providing informal support.  Logs provided show the member needing assistance with toileting every 2-3 hours through the night.

Yes. The proposed treatment is medically necessary.
No. The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

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. This member has severe dementia. He is appealing denial of increase personal care aide (PCA) and consumer directed personal assistance program (CDPAP) services for a total of 168 hours per week. The plan approved personal care aide and consumer directed personal assistance program live-in per diem 7 days per week. Uniform Assessment System (UAS) evaluation completed previously shows the member requires assistance with all ADLs (activities of daily living). He has bowel and bladder incontinence. He is wheelchair bound. Appeal statements note there has been a decline in cognitive and physical functioning. He needs assistance with toileting every 2-3 hours through the night. This member has continuous needs that cannot be met with the approved personal care aide and consumer directed personal assistance program live-in per. The proposed increase in personal care aide and consumer directed personal assistance program services for a total of 168 hours per week is medically necessary to meets this member's need for assistance with activities of daily living and personal care.