Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Parkinson's Disease, dementia, diabetes, hypertension, seizures, and arthritis.
Treatment:  Increase Consumer Directed Personal Assistance Program (CDPAP) Services 12 Hours per Day 7 Day(s) per week for a Total of 168 Hours Per Week (split shift).

The insurer denied: Increase Consumer Directed Personal Assistance Program (CDPAP) Services 12 Hours per Day 7 Day(s) per week for a Total of 168 Hours Per Week (split shift).  The denial is upheld.

The patient is an elderly female with Parkinson's Disease, dementia, diabetes, hypertension, seizures, and arthritis. The request is for Increase in Consumer Directed Personal Assistance Program (CDPAP) Services 12 Hours per Day 7 Day(s) per week for a Total of 168 Hours Per Week (split shift) from CDPAP (Consumer Directed Personal Assistance Program) 7.5 hours per day, 6 day(s) per week for a total of 45 hours per week. A provider letter notes that the patient has significant physical and psychiatric needs and needs total assistance with activities of daily living. The Uniform Assessment System (UAS) evaluation completed on 3 months ago reflects that the patient required maximal assistance for bathing and dressing. The patient is totally dependent for housework, meal preparation, and toilet use. She required maximal assistance for bathing, personal hygiene, medication management, dressing and walking. She requires extensive assistance with eating. She uses a wheelchair and a scooter. A tasking tool completed last year estimated a need for 54 hours per week of services. The plan issued an initial partial denial, approving CDPAP (Consumer Directed Personal Assistance Program) 9 Hours/Day, 7 day(s) per week, for a total of 63 Hours per week. The letter notes that the patient had declined in several functional areas and that the increase to 63 hours per week would meet the patient's needs. A handwritten appeal states that the patient "cannot stand up or walk" and cannot dress, bathe herself, or get into bed on her own. 

The requested Increase Consumer Directed Personal Assistance Program (CDPAP) Services 12 Hours per Day 7 Day(s) per week for a Total of 168 Hours Per Week (split shift) is not 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. The submitted documentation does not reflect which activities of daily living cannot be completed within the currently approved 63 hours per week. Time for housework, meal preparation, personal hygiene, toileting, and dressing, have already been accounted for in the hours approved by the plan. A tasking tool completed 3 months ago shows that the patient requires 9 hours per day for a total of 54 hours per week for her activities of daily living, indicating that the plan-approved 63 hours per week adequately meet the patient's needs. Moreover, there is no evidence of frequent night-time personal care needs (e.g., frequent turning, frequent toileting needs). While the submitted documentation indicates that the patient has dementia and is a fall risk, personal care services are not covered for supervision and safety concerns. Additionally, the CDPAP (Consumer Directed Personal Assistance Program) program allows the patient's designated representative the flexibility to allocate the approved hours in a way that best meets the patient's needs. Based on the available information, 9 hours per day, 7 days per week (63 hours per week) of Consumer Directed Personal Assistance Program are sufficient to meet the patient's needs. Thus, the Increase Consumer Directed Personal Assistance Program (CDPAP) Services to a Split Shift for a Total of 168 Hours Per Week is not medically necessary.