Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tibia fracture, muscle weakness, syncope, HTN (hypertension), HPL (hyperlipidemia), gout, NSTEMI (non-ST elevation myocardial infarction), MDD (major depressive disorder), GERD (gastroesophageal reflux disease), A. fib (atrial fibrillation), UTI (urinary tract infection), muscle wasting and atrophy and pain
Treatment: Increase in Consumer Directed Personal Assistance Program (CDPAP) Services to 12 hours per day, 7 days per week, for a total of 168 hours per week (split shift)
The insurer denied the increase in Consumer Directed Personal Assistance Program (CDPAP) services to 12 hours per day, 7 days per week, for a total of 168 hours per week (split shift).
The denial is overturned. 

The patient is a female with several conditions, including tibia fracture, muscle weakness, syncope, HTN (hypertension), HPL (hyperlipidemia), gout, NSTEMI (non-ST elevation myocardial infarction), MDD (major depressive disorder), GERD (gastroesophageal reflux disease), A. fib (atrial fibrillation), UTI (urinary tract infection), muscle wasting and atrophy and pain. The patient is appealing denial of 168 hours per week, split shift, CDPAP (consumer directed personal assistance program). The patient was approved for 59.5 hours per week.

An appeal letter from the patient's provider states that the patient was residing in skilled nursing and rehab. She has significant weakness and cognitive deficits that require one-to-one care 24/7 for assistance with ADLs (activities of daily living). They note that the patient needs frequent assistance with toileting during the night.

An appeal letter from a second provider states the patient has dementia, UTIs, and high risk of falling. They recommend 24/7 assistance with ADLs, especially at night for toileting.

Progress reports from SNF (skilled nursing facility) are provided and show UTIs. The patient requires turning and positioning every two to four hours, and she receives incontinence care every two to four hours. She has recurrent falls in SNF and pre-hospital fall resulting in tibia fracture. She requires assistance with bathing, dressing, transferring, and toileting and supervision with bed mobility, and personal hygiene.

Yes, the increase in CDPAP services to 12 hours per day, 7 days per week, for a total of 168 hours per week (split shift) is medically necessary.

Medically necessary services are those which are:

1) safe 2) effective 3) generally accepted national standard of medical practice 4) not provided primarily for convenience of the patient or the practitioner 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice.

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 provider five hours daily of uninterrupted sleep during the aide's eight-hour period of sleep. The patient has several chronic conditions, including cognitive deficits and weakness. Weakness and mobility limitations make the patient an increased fall risk. She has recurrent falls and recent hospitalization due to tibia fracture as result of a fall. The patient requires assistance with ADLs throughout the day and nighttime due to limited mobility and urinary incontinence. Every two to four hours, she requires repositioning and urinary incontinence care. These needs require uninterrupted personal care. The proposed increase in CDPAP services to 168 hours per week, split shift, is medically necessary and in the best interest of the patient.