Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia and multiple strokes
Treatment: Consumer Directed Personal Assistance Services, 24 Hours per Day, Seven Days per Week (Split Shift)
The insurer denied the Consumer Directed Personal Assistance Services, 24 Hours per Day, Seven Days per Week (Split Shift)
The denial is overturned. 

This female has conditions including dementia and multiple strokes.  The patient's daughter is appealing denial of consumer directed personal assistance services (CDPAS) 24 hours per day, split shift.  The daughter states the patient's cognition and functioning are worse.  The appeal states the patient needs help with turning in the bed, toileting and needs supervision when not sleeping at night. Her request has been partially approved from consumer directed personal assistance services (CDPAS) 91 hours total to 24 hours per day, live in.  The patient lives alone.  Uniform Assessment System (UAS) evaluation performed showed the patient needs assistance with meal preparation, housework, laundry, shopping, dressing, bathing, eating, toileting, and personal hygiene.  She is incontinent of bowel and bladder. 

Appeal statement from the daughter states the patient requires total care with all activities of daily living (ADLs).  It states the patient is immobile and confined to a wheelchair.  It notes the patient's status has declined over the past six months.  It states that during the night, the patient requires diaper changes every three to five hours, repositioning ever three to four hours, pain management and feeding.  The daughter is no longer able to provide nighttime support. There is a statement  from the provider that notes the patient is wheelchair bound and cannot function independently.  It states the patient needs repositioning every two hours due to incontinence of bladder and bowel.  The patient has advanced dementia.  It recommends 24 hour, split shift aid. A statement from the power of attorney (POA) notes that the patient has poor detention, she does not eat well and wakes up at night hungry.

Yes, the proposed treatment is medically necessary.

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. 

This patient has multiple chronic conditions including dementia and is status post multiple strokes.  She is immobile and wheelchair bound.  The patient's daughter is appealing denial of consumer directed personal assistance services (CDPAS) 24 hours per day, split shift.  She was approved for 24 hours per day, live-in.  Uniform Assessment System (UAS) evaluation performed shows the patient requires assistance with meal preparation, housework, laundry, shopping, dressing, bathing, eating, toileting, and personal hygiene.  She is incontinent of bowel and bladder.  Appeal statements indicate that the patient's cognitive and functional status have declined.  During the nighttime, she requires diaper changes and frequent repositioning.  This patient has continuous needs for assistance with activities of daily living (ADLs) / instrumental activities of daily living (IADLs).  Based on the nighttime needs that include frequent repositioning, it is unlikely that the aide would obtain five hours daily of uninterrupted sleep.  The approved consumer directed personal assistance service (CDPAS) 24 hours per day, live-in, is inadequate to meet this patient's needs.  The proposed consumer directed personal assistance service (CDPAS) 24 hours per day, split shit, is medically necessary to meet this patient's needs.