Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, macular degeneration, legal blindness, and osteoarthritis
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Services to 168 Hours/Week
The insurer denied an increase in CDPAP services to 168 hours/week.
The denial is overturned.

The patient is an elderly female. Her conditions include dementia, macular degeneration, legal blindness, and osteoarthritis. Denial of an increase in consumer directed personal assistance program (CDPAP) services to 168 hours/week is being appealed. The health plan approved an increase from 56 to 63 hours/week.

Uniform Assessment System (UAS) evaluation shows severely impaired cognition and functioning with total dependence with meal preparation, housework, managing finances, shopping, and personal hygiene; maximal assistance with managing medications, bathing, dressing, walking, locomotion, and toileting; and extensive assistance with bed mobility and eating. The patient has weakness and limited range of motion. She has bowel and bladder incontinence. Compared to UAS evaluation completed previously, there has been a decline with toilet transfer, walking, locomotion, eating, and bed mobility.

An appeal statement notes the patient needs 24 hour split shift care, based on needs for assistance with ADLs (activities of daily living). A letter from the patient's provider states the patient is unable to perform ADLs due to dementia and blindness. She is unable to perform ADLs as already accounted for in the UAS evaluation. Night logs are provided and show assistance every 2-3 hours with toileting.

The increase in CDPAP services to 168 hours/week 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 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 an increase in CDPAP services to 168 hours/week is being appealed. The health plan approved an increase from 56 to 63 hours/week.

This patient has multiple chronic conditions. UAS evaluation shows the patient requires assistance with all ADLs. She is incontinent of bowel and bladder. Compared to UAS evaluation completed previously, there has been a decline with toilet transfer, walking, locomotion, eating, and bed mobility. Appeal statements note the patient is unable to perform ADLs without assistance. Night logs show the patient needs assistance every 2-3 hours with toileting. The information provided show that this patient has significant limitations in functioning. The assistance she requires during day and night, is unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved CDPAP 63 hours/week is insufficient to meet this patient's needs for assistance with ADLs. The requested increase in CDPAP services to 168 hours/week is medically necessary.