Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, glaucoma, recent right hip replacement and cognitive deficits

Treatment: Consumer Directed Personal Assistance Services (CDPAS) 2 days per week 2-12 hours split shift (48 hours per week)

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS) 2 days per week 2-12 hours split shift (48 hours per week)

The denial is overturned

This is a geriatric patient with heart disease, glaucoma, recent right hip replacement and cognitive deficits. The patient lives with a daughter in a private residence. The patient is approved by the insurer for Consumer Directed Personal Assistance Services (CDPAS) 12 hours per day, 7 days per week. The insurer also approved the Consumer Directed Personal Assistance Program (CDPAP) 24 hours per day live in (Saturday and Sunday). The patient's daughter declined the CDPAP 24 hours per day live-in (Saturday and Sunday) and is requesting CDPAS, 2 days per week 2-12 hours split shift (48 hours per week); which is currently under review. 

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as "moderately impaired- decisions consistently poor or unsafe; cues/supervision required at all times."  The patient requires maximal assistance for bathing, dressing and toilet use. Extensive assistance is needed for personal hygiene, bed mobility, locomotion, ambulation, and toilet transfer. The patient is frequently incontinent of bladder and occasionally incontinent of bowel. The patient requires limited assistance for eating. Compared to the UAS report, the patient's cognitive and functional status is the same. 

The patient's daughter reports that the patient becomes restless at times, gets out of bed, wanders and has fallen on several occasions. The patient's daughter writes, "since I have been staying with him and paying out of my own funds for a 12-hour split home aide, we have managed to have no incidents but prior to that the patient had 4 documented falls in a 3-5-week period." The physician also notes the insurer approved CDPAP 24 hours per day live in (Saturday and Sunday). However, the patient's medical condition and functional ability are at a level or unpredictable as to require the requested CDPAS 24 hours per day, 2 days per week (split shift). Based on the records reviewed, the approved live-in CDPAP is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain an uninterrupted 5 hours of sleep. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained at home with the requested CDPAS, 2 days per week 2-12 hours split shift (48 hours per week). Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based. From a physical medicine and rehabilitation perspective, CDPAS 2 days per week 2-12 hours split shift (48 hours per week) is medically necessary. 

Based on the above, the insurer's denial must be overturned. 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 consumer directed personal assistance services (CDPAS) 2 days per week 2-12 hours split shift (48 hours per week) is substantiated.