Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, chronic kidney disease, dementia, diabetes, and pressure ulcers.
Treatment: Consumer Directed Personal Assistance Services (CDPAS); 24 Hours Continuous Care, 7 Days/Week (split shift).
The insurer denied the CDPAS; 24 hours continuous care, 7 days/week (split shift).
The denial is overturned.

The patient is a female. Her conditions include Parkinson's disease, chronic kidney disease, dementia, diabetes, and pressure ulcers. She lives with her son and daughter-in-law. Denial of consumer directed personal assistance services (CDPAS) 24 hours continuous care, 7 days/week, split shift, is being appealed. The plan approved 24 hour live-in, 7 days/week.

Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and maximal assistance to total dependence with all ADLs (activities of daily living). The patient is bed- and wheelchair-bound. She must be repositioned every 2 hours to avoid further skin breakdown. She has bowel and bladder incontinence. Medical records and visit notes are provided for review. Nighttime logs are provided that show frequent turning/repositioning.

An appeal letter indicates the patient is totally dependent on the assistance of others. She is bed- and wheelchair-bound and incontinent of bladder and bowel. She requires turning and positioning for pressure ulcers. Her family is unable to provide informal support.

Yes, the requested CDPAS; 24 hours continuous care, 7 days/week (split shift) is 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 service 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 CDPAS 24 hours continuous care, 7 days/week, split shift, is being appealed. The health plan denied coverage for the request because the patient did not require continuous/hands-on care that would prevent an aide from obtaining 5 hours of uninterrupted sleep. The plan approved 24 hour live-in, 7 days per week.

This patient has multiple chronic conditions, and is bed- and wheelchair-bound. UAS evaluation completed shows the patient requires assistance with all ADLs. She is incontinent of bowel and bladder. She has pressure ulcers and requires assistance with turning/repositioning. Frequent turning/repositioning is supported by nighttime logs. The records and appeal statements support the patient is dependent with all ADLs and requires assistance with turning/repositioning. This patient has continuous needs, including frequent turning/repositioning that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved CDPAS, live-in, 7 days per week is insufficient to meet the patient's needs for assistance with ADLs and personal care. The requested CDPAS 24 hours continuous care, 7 days/week, split shift, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.