Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchenne Muscular Dystrophy
Treatment: Consumer Directed Personal Assistance services (CDPAS) 2 12 hour split shifts per day 7 days/week (Monday through Sunday), a total of 168 hours 
The insurer denied CDPAS 2 12 hour split shifts per day 7 days/week (Monday through Sunday), a total of 168 hours.
The denial is overturned.

The patient is a male with medical history notable for Duchenne Muscular Dystrophy. The patient is approved for 24 hours/day live-in, 7 days/week of Consumer Directed Personal Assistance Services (CDPAS). The patient and his care team requested an increase to 24-hour split-shift (2 12 hour shifts), 7 days/week (168 hours/week) of CDPAS. This request was denied by the health plan and this denial is the subject under review. A letter of support for this appeal was provided by the patient's physician. The letter states that "he will need 24 hour care" due to his conditions, but does not disclose further detail.

Another physician wrote a letter of support for this appeal. This letter states that the patient requires "total assistance with all activities of daily living. He is immobile, blind, and dependent on respiratory equipment 24 hours per day." The letter states that it is imperative that he receive continuous care to address toileting, turning/positioning, and correct application of his respiratory equipment.

An office visit note from pulmonology was provided for review. The note details the procedures necessary for managing his respiratory equipment.

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was completed via teleconference. The patient had a Mini-Mental State Examination (MMSE) score of 25. He is unable to read and write due to blindness and inability to hold a pencil. He is not able to care for himself in an emergency or call for help so he can "never be alone." For his functional status, he requires total dependence for housework, stairs, and transportation. He requires maximal assistance for meal preparation, finances, medications, and shopping. For his activities of daily living (ADLs), he requires total dependence for nearly all, including bathing, hygiene, dressing, locomotion, toilet use, and eating. He requires limited assistance for bed mobility. He is on a ventilator 24 hours/day. He is continent of urine and stool.

The requested health service/treatment of CDPAS 2-12 hour split shifts/day 7 days/week (Monday through Sunday), a total of 168 hours is medically necessary for this patient.

The patient is approved for a live-in personal care aide and was denied the request for split-shift 24 hour care. A live-in aide requires 8 hours of rest at night and the expectation of at least a 5 hour window of uninterrupted rest. If the patient has personal care needs that preclude this window of uninterrupted rest, then split-shift care is medically necessary.

The patient has multiple personal care needs that prevent him from being left alone for 5-8 hours overnight. He is unable to perform any ADLs without complete dependence on others. He has night time needs with toileting, position change, and equipment readjustment. Furthermore, he cannot make these needs known if his aide is not readily available. An aide would not be able to safely leave him overnight. The patient's physicians attested to his personal care needs and the medical necessity of split shift care.