Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's, Osteoarthritis

Treatment: 24 hours a day, 7 days a week (split shift) for a total of 168 hours for consumer direct personal assistance services (CDPAS)

The insurer denied coverage for 24 hours a day, 7 days a week (split shift) for a total of 168 hours for consumer direct personal assistance services (CDPAS).

The denial is overturned.

This patient has extensive functional impairments associated with various medical conditions, including Alzheimer's Disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) stage 3, hearing loss, incontinence, and osteoarthritis. The patient needs substantial assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient lives alone. The patient receives some informal help from their children. The Uniform Assessment System (UAS) report indicates informal help is provided for ADLs and IADLs, but the external appeal letter from the patient advocate indicates the family assists with some IADLs, but cannot assist with ADLs. The patient primarily relies on personal care services, provided through Consumer Directed Personal Assistance Services (CDPAS) for assistance with most daily activities. The patient receives CDPAS 24 hours per day, 7 days per week (live-in), total of 91 hours per week. The patient (via designee) requested CDPAS 24 hours per day, 7 days per week (split shift), total of 168 hours per week, which was denied. External appeal was requested. 

The most recent UAS (Uniform Assessment System) provided was reviewed. The functional status report indicates the patient is totally dependent for all IADLs, except managing medications (maximal assistance); and the patient is totally dependent for all ADLs, except eating (maximal assistance). As per UAS, the patient is bedbound, but some notes in the aide's activity logs indicate the patient is transferred at times to a recliner.  

The patient is totally dependent for IADLs, which is likely due to both cognitive and physical impairment. Regarding ADLs, in later stages of dementia, the affected person may not remember, recognize, or know what to do for basic ADLs. The UAS indicated the patient has difficulty participating in ADLs because they can no longer follow instructions. It appears the high level of assistance the patient needs for all ADLs is probably due to the combined effects of physical and cognitive decline.

Regarding behavioral problems associated with dementia, the UAS reports the patient resists care at times and has a history of frequent delusions and hallucinations. The physicians' letters reported the patient has increased agitation/anxiety at night. Behavioral disturbances associated with dementia are often unpredictable. Adverse behaviors can interfere with daily care, with potential harm to the patient (e.g., risk of falls/accidents, decreased food/fluid intake, refusing medications). It is often a source of distress for the caregiver, as providing care becomes more difficult. 

The records provided for review indicate the timing and frequency of the patient's ADL/IADL care needs, and her behavior and sleep patterns do not provide a consistent opportunity for 5 uninterrupted hours of sleep per day for a live-in aide. Live-in services do not appear to meet the patient's daily care needs, and so continuous personal care services (in this case CDPAS) are indicated.
 
Based on the above, the insurer's denial must be reversed. 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 24 hours a day, 7 days a week (split shift) for a total of 168 hours for consumer direct personal assistance services (CDPAS) is substantiated.