Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, vascular dementia, hypertension, hyperlipidemia, colon cancer, chronic kidney disease, osteoarthritis. 
Treatment: Consumer Directed Personal Assistance Program (CDPAP), 8 hours per day, 7 days per week for a total of 56 hours per week. 

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP), 8 hours per day, 7 days per week for a total of 56 hours per week. 

The denial is overturned. 

This female of advanced age has functional decline due to several medical conditions and needs assistance for all daily activities. The patient lives with her son and granddaughter. She receives Consumer Directed Personal Assistance Program (CDPAP) services, 5 hours per day, 7 days per week, total of 35 hours per week. Family provides some informal care during non-CDPAP hours. 

Level of care for bathing, dressing, walking, transfers are similar UAS (uniform assessment system). For meals, patient needs supervision during meals to encourage adequate intake. Grooming/personal hygiene declined from limited assistance to what appears to be almost total dependence; except patient can brush her teeth with prompting after toothpaste is put on toothbrush. Toileting appears to have become a more complicated issue. The patient has diagnosis of urinary retention with overflow incontinence. She needs intermittent catheterization 1-2 times per day (granddaughter was trained to perform this task). It is reported as time-consuming. Patient also has chronic stool leakage. Due to her slow mobility, she also has functional incontinence, as she often does not reach the toilet in time when she has the urge. It was noted that clothing is often changed more than once a day due to soiling. Toileting related tasks appear to need more frequent attention from a caregiver to ensure proper cleaning/hygiene, incontinence care, and safety when using the toilet. 

The patient is totally dependent for meal preparation and service. Granddaughter noted that it is unlikely patient would have a meal if she were alone. If a caregiver is not present at each meal, the patient's food and fluid intake will probably decline, and increase her risk for weight loss, malnutrition and dehydration. In later stages of dementia, food and fluid intake often declines due to various behavioral and/or physical problems, such as dysphagia; pocketing food in the mouth; loss of interest/appetite for eating. The patient is underweight (based on BMI (body mass index) 17.6 calculated from UAS height/weight). The granddaughter reported patient needs to be served food and fluids and supervised/encouraged to eat, and probably (when necessary) assist with feeding. She has CKD (chronic kidney disease) and needs to maintain hydration. It is medically necessary that a caregiver is present for all food and fluid intake to provide cues and prompts to encourage the patient to eat and drink. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for Consumer Directed Personal Assistance Program (CDPAP): 8 hours per day, 7 days per week for a total of 56 hours per week is overturned. Medical Necessity is substantiated.