Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied an increase in Consumer Directed Personal Assistant Program (CDPAS) to continuous care (split shift). 
The denial was overturned. 

The patient is a female with a past medical history of osteoarthritis, obesity, dementia, diabetes mellitus type 2, osteoporosis, hypothyroidism, coronary artery disease, hyperlipidemia, depression, vertigo, urinary incontinence, and fecal incontinence who had been assigned Consumer Directed Personal Assistant Program (CDPAP) services 24 hours/day, live-in, 7 days/week with a request to increase to 24 hours/day split-shift personal care aide (PCA) services who underwent an assessment tool over the telephone. The patient was assessed at total assistance with meal preparation, ordinary housework, managing finances, meal preparation, stairs, shopping, bathing, dressing lower body, and locomotion while maximum assistance with tasks of phone use, transportation, transfer toilet, toilet use, and bed mobility. Activity did not occur for tasks of equipment management or walking, and patient was assessed at extensive assistance with eating. The patient's daughters take turns sleeping overnight to assist the patient and the patient lives alone. The assessment also noted the patient had a fall when trying to get on the commode independently. It took 1 person to move her from bed to commode and the patient asked to move from her bed to commode several times at night. Notes also stated the patient wears pull-ups and has frequent incontinence of bowel and bladder.
The insurer provided final adverse determination denial notice denying request to increase to split shift PCA services noting the request was not medically necessary and the patient did not meet criteria, as well as stating the patient's doctor did not document a medical condition that directly caused her to need frequent assistance throughout the night with such frequency that a live-in personal care aide would be unable to provide the required care. 
At issue is the medical necessity of Increase in Consumer Directed Personal Assistant Services (CDPAS) to continuous care (split shift) personal care aide (PCA) services.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Increase in Consumer Directed Personal Assistant Services (CDPAS) to continuous care (split shift) personal care aide (PCA) services is medically necessary for this patient.
The patient has documented chronic and progressive medical conditions of osteoarthritis, osteoporosis, and dementia with both urinary and fecal incontinence. There is documentation of 2 falls in the overnight hours when the patient was unassisted to the bathroom. The patient requires assistance with all activities of daily living (ADL)s and Instrumental activities of daily living (IADL)s. The patient's medical provider documented the need for frequent repositioning every 2 hours with diaper change to prevent bed ulcers. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's overnight care needs would not allow a PCA 5 hours of uninterrupted sleep. The requested increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. 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 her own home.
Therefore, the requested health service/treatment of Increase in CDPAS to continuous care (split shift) personal care aide (PCA) services is medically necessary.