Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease, GERD (gastroesophageal reflux disease), anemia, hearing loss, and osteoarthritis.
Treatment: Increase Consumer Directed Personal Assistance Services (CDPAS) To 7 Days Per Week, 12 Hours Per Day, 12 Hours x 2 (split shift) Continuous by More than One Person, 168 Hours Per Week.

The insurer denied Increase Consumer Directed Personal Assistance Services (CDPAS) To 7 Days Per Week, 12 Hours Per Day, 12 Hours x 2 (split shift) Continuous by More than One Person, 168 Hours Per Week.  The denial is upheld.

The patient is an elderly male. His medical conditions include coronary artery disease, GERD (gastroesophageal reflux disease), anemia, hearing loss, and osteoarthritis. Denial of Increase consumer directed personal assistance services (CDPAS) to 7 days per week, 12 hours per day, 12 hours x 2 (split shift) continuous by more than one person, 168 hours per week is being appealed. The health plan approved 7 days per week, 24 hours per day, live-in, 91 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed last month shows moderately impaired cognition and need for assistance with all ADLs (activities of daily living). He has bowel and bladder incontinence. He had a fall last month when coming down the stairs. Appeal statements indicate the patient has hallucinations, jumps out of bed, wants to use bathroom every half hour, and needs to be watched constantly due to imbalance. He does not sleep more than 45 minutes at a time.

The Increase Consumer Directed Personal Assistance Services (CDPAS) To 7 Days Per Week, 12 Hours Per Day, 12 Hours x 2 (split shift) Continuous by More than One Person, 168 Hours Per Week is not medically necessary. 

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. Denial of Increase consumer directed personal assistance services (CDPAS) to 7 days per week, 12 hours per day, 12 hours x 2 (split shift) continuous by more than one person, 168 hours per week is being appealed. The health plan approved 7 days per week, 24 hours per day, live-in, 91 hours per week. This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed last month shows the patient requires assistance with all ADLs (activities of daily living). He is incontinent of bowel and bladder. The appeal statements support the patient is requires assistance with all ADLs (activities of daily living). These statements report the patient hallucinates and has problems with sleep. Additional care is requested for constant monitoring. This patient does not continuous needs that require services of an aide. CDPAS (consumer directed personal assistance service) is not indicated for supervision. The approved CDPAS (consumer directed personal assistance service) 7 days per week, 24 hours per day, live-in, 91 hours per week is appropriate for this patient. The requested increase CDPAS (consumer directed personal assistance service) to 7 days per week, 12 hours per day, 12 hours x 2 (split shift) continuous by more than one person, 168 hours per week is not medically necessary.