Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, mixed incontinence, sacral ulcer, dementia, gait abnormality, oxygen-dependent respiratory failures and hypertension.
Treatment: Increase Consumer Directed Personal Assistance Services from 70 Hours to 150 Hours per week.
The insurer denied the Increase Consumer Directed Personal Assistance Services from 70 Hours to 150 Hours per week.
The denial is overturned.

The patient is a male. His conditions include Parkinson's disease, mixed incontinence, sacral ulcer, dementia, gait abnormality, oxygen-dependent respiratory failures and hypertension. He is bed-bound. This appeal is regarding denial of Consumer Directed Personal Assistance Services 150 hours per week. He has been approved for 70 hours per week.

UAS (Uniform Assessment System) evaluation completed earlier this year shows severely impaired cognitive impairment and functional status: total dependence with meal preparation, housework, managing finances and medication, shopping equipment management, bathing, personal hygiene, dressing, locomotion, toileting, bed mobility, and eating. The patient is bed-bound. There is no physical activity. He is incontinent of bowel and bladder.

An appeal letter from a provider states the patient was receiving 56 hours per week before being hospitalized earlier this year with COVID-19 pneumonia. After discharge, the family requested 24 hour, split service. It is noted the patient needs assistance with all ADLs (activities of daily living) and needs uninterrupted care. Letters from the patient's physicians indicate the patient is bed bound and requires full assistance with all ADLs (activities of daily living). It is further noted he has unscheduled needs throughout nighttime hours. He needs repositioning every two hours to prevent further deterioration of pressure wounds.

Yes, the Consumer Directed Personal Assistance Services 150 hours per week are medically necessary.
Medically necessary services are those which are:
1) safe 
2) effective
3) generally accepted national standard of medical practice 
4) not provided primarily for convenience of the patient or the practitioner 
the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested health service is medically necessary, because it is consistent with generally accepted national standards of medical practice.

This patient has multiple chronic conditions, including Parkinson's disease and dementia. He was hospitalized earlier this year with COVID pneumonia. He is bed-bound and oxygen-dependent. He has been approved for Consumer Directed Personal Assistance Services 70 hours per week.

UAS (Uniform Assessment System) evaluation performed earlier this year shows the patient is totally dependent with ADLs/IADLs (activities of daily living/instrumental activities of daily living). He is incontinent of bowel and bladder. He requires repositioning/turning every two hours due to pressure ulcers. This patient has significant cognitive and functional impairment. He requires complete care with ADLs/IADLs (activities of daily living/instrumental activities of daily living) and needs frequent repositioning/turning. The approved Consumer Directed Personal Assistance Services 70 hours per week is inadequate to meet this patient's needs. Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. 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 provider five hours daily of uninterrupted sleep during the aide's shift. Consumer Directed Personal Assistance Services increase from 70 to 150 hours per week is medically necessary to meet this patient's need for assistance with ADLs (activities of daily living) and personal care.