Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dementia
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week
The insurer denied the Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week.
The health plan's determination is partially overturned to provide personal assistance services (PAS) for 10 hours a day, for 7 days a week for a total of 70 hours. 

The patient is a female with a history of dementia, urinary incontinence and gait instability who lives alone in a pent house. She is oriented to person and place but not time and is often forgetful. Recently she has had increasing confusion. She also has baseline forgetfulness. She is hard of hearing at baseline. Due to her cognitive and physical debility, she needs maximal assistance (greater than (>)50 percent (%)) for meal prep, medication management, phone use, shopping and transportation. She needs extensive assistance for bathing, personal hygiene and dressing upper body and lower body. However, she needs limited assistance for ambulation and bed mobility. She typically uses assistive devices for ambulation. She recently has had increasing dementia, progressive forgetfulness, bowel and bladder incontinence and agitation. She is unable to participate in household work due to her forgetfulness. She also needs weight bearing assistance for brushing her teeth. She is able to walk indoors and outdoors without assistance and with minimal cueing. She is able to move in bed from side to side with light touch and back and forth with some guidance. Recently her activities of daily living (ADL's) have declined for toilet use, eating, bed mobility and overall self-sufficiency due to her dementia.

The health plan did not act reasonably in its determination of the medical necessity. She initially had 5.5 hours per day, 7 days a week for a total of 38.5 hours approved for personal assistance. However, her hours were increased to 6 hours a day for total of 42 hours a week. In their determination, the health plan quoted that the member's daughter directs her care and she is able to walk without assistance and bathe with some guidance. She has a supportive family that is involved in her care. However, based on the most recent assessment performed she had progressive dementia, disorientation, use of an assistive device for ambulation and extensive assistance was needed for personal hygiene and dressing. The patient needs supervision for locomotion and walking as well as transfers for toileting. Although she has maximal family support available there is concern for her progressive dementia and the fact that she lives alone. Her family is not around her 24 hours a day, 7 days a week due to other obligations. However, assistance is not necessary for 24 hours a day, for 7 days a week. Based on the patient's needs and her living situation the recommendation is for the provision of personal assistance services (PAS) for 10 hours a day 7 days a week for a total of 70 hours. 

According to a study the need factors (ADL's and Instrumental activities of daily living (IADL's)) were the most important predictors of hours of help. In all the models examining paid and unpaid hours of help, bathing was the most important ADL measure in predicting hours, (as was required for the patient as she needs full assistance), controlling for other ADL's and IADL's for which help was received. According to this study, the informal providers fail to provide as many hours of help to the people to meet their personal assistance needs and that's why she needs formal and trained assistance for her care [1].