Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, coronary heart disease, and depression
Treatment: Increase Consumer and Self-Directed Personal Assistance Service (CDPAS) 24 Hours Per Day, 7 Days Per Week (split shift)
The insurer denied Increase Consumer and Self-Directed Personal Assistance Service (CDPAS) 24 Hours Per Day, 7 Days Per Week (split shift).
The denial is upheld.

The patient is an elderly male. His medical conditions include dementia, coronary heart disease, and depression. He lives alone. Denial of increase consumer and self-directed personal assistance service (CDPAS) 24 hours per day, 7 days per week (split shift) is being appealed. The health plan approved consumer and self-directed personal assistance service 56 hours a week. The patient's Uniform Assessment System (UAS) evaluation completed 2 months ago shows moderately impaired cognition and functional status: total dependence with housework, managing finances, and shopping; maximal assistance with meal preparation, managing medications, phone use, and transportation; extensive assistance with stairs, bathing, and dressing; limited assistance with personal hygiene, walking, locomotion, and toileting; and supervision with bed mobility and eating. He requires a cane for ambulation but is noncompliant with use due to impaired cognition. He has impaired safety awareness and has a history of frequent falls. He had a fall 2 months ago. He is continent of bowel and bladder.

The requested Increase Consumer and Self-Directed Personal Assistance Service (CDPAS) 24 Hours Per Day, 7 Days Per Week (split shift) is not medically necessary. 

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transferring, turning/positioning, or feeding. 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 who 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 increase consumer and self-directed personal assistance service (CDPAS) 24 hours per day, 7 days per week (split shift) is being appealed. The health plan approved activities of daily living 56 hours a week. This patient has a primary diagnosis of dementia. Uniform Assessment System (UAS) evaluation completed 2 months ago shows he needs assistance with all activities of daily living, except bed mobility and eating. He does not have incontinence. He has impaired safety awareness due to impaired cognition. He has a history of frequent falls. The patient lives alone. The information provided does not support that the tasks being performed require 24-hour continuous care. CDPAS (consumer directed personal assistance service) is not indicated when no tasks are being performed or for safety supervision. The currently approved CDPAS (consumer directed personal assistance service) 56 hours per week is appropriate to meet the patient's need for assistance with activities of daily living. The requested CDPAS (consumer directed personal assistance service) 24 hours per day, 7 days per week (split shift) is not medically necessary.