Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer directed personal assistance services (CDPAS)- 7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person of consumer directed personal assistance services.
The insurer denied consumer directed personal assistance services (CDPAS)- 7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person of consumer directed personal assistance services.
The determination is overturned.

This is a male patient with a past medical history of dementia, urinary incontinence, bowel incontinence, lymphoma, and obesity who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 91 hours/week. The patient had a video assessment. The patient was seen by oncology with an office note documenting the patient's aide had noted worsening cognitive deficit, difficulty forming speech, increased confusion, and worsening mobility due to right leg shaking. The patient was prescribed Ambien.
An office visit note with the primary care physician (or provider) (PCP) documented that the patient was brought in urgently due to worsening dementia with periods of hallucinations, confusion, and deteriorating functional status. The provider documented the patient's problems had been progressive over several months and the patient needed assistance with all of his activities of daily living (ADLs). In addition, the office note stated the patient continued to have insomnia at night and had tried multiple medications, most recently Ambien that had been provided by oncology but was discontinued by the PCP with concern that this was causing worsening confusion. Overnight care logs documented overnight care needs at least every 3-1/2 hours.
There was a request to increase CDPAP services and the patient underwent an assessment.  
The insurer sent a final adverse determination denial notice denying request to increase CDPAP services to 7 days/week, 24 hours/day, split shift stating the patient's care needs could be met with services 7 days/week, 24 hours/day, live in combined with additional specialized equipment as medically appropriate. The denial also recommended the patient continue to follow-up with medical providers, use durable medical equipment (DME) that was provided, a condom catheter, and a hospital bed. The patient's hematologist/oncologist provided a letter stating the patient was receiving chemotherapy and the patient had multiple comorbidities and was wheelchair-bound. The note also stated the patient was currently hospitalized with tachycardia and deep vein thrombosis (DVT) and would require full-time care at home. The patient's geriatrician also provided a letter stating that the patient had multiple medical conditions including advanced dementia with hallucinations, mantle cell lymphoma, osteoarthritis, and gait instability and the patient was homebound, bedbound and needed in-home care throughout the day and night. The geriatrician's letter also stated the patient needed a home health aide to assist with toileting, bathing, dressing, transferring, turning and positioning at night. The provider recommended an aide for 12 hours of split shift services to assist with the patient's care and maintain the patient's safety. The patient and his family appealed the denial decision. 
At issue is the medical necessity of consumer directed personal assistance services (CDPAS)- 7 days per week, 24 hours per day, 168 hours per week, continuous care by more than one person of consumer directed personal assistance services.

The services are medically necessary. There is documentation of worsening cognitive and physical functioning. There is documentation by the patient's medical providers of medical necessity for split shift services. There are overnight care logs documenting assistance needs with activities of daily living (ADLs) that would not allow an aide to obtain at least 5 hours of uninterrupted sleep. In addition, the patient's medical diagnosis of Alzheimer's has created symptoms of insomnia and despite medication the patient is up at night requiring assistance with walking and locomotion. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 7 days per week, 24 hours per day, 168 hours per week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.