Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, osteoporosis, anxiety, urinary incontinence, and hearing impairment
Treatment: Increase Consumer Directed Personnel Assistance Service (CDPAS) 24 Hours a Day 7 Days a Week (Split Shift) for a Total of 168 Hours a Week
The insurer denied: Increase Consumer Directed Personal Assistance Service (CDPAS) 24 Hours a Day 7 Days a Week (Split Shift) for a Total of 168 Hours a Week 
The denial is overturned.

This elderly female has conditions including Alzheimer's disease, osteoporosis, anxiety, urinary incontinence, and hearing impairment. She is appealing the denial of an increase in consumer directed personal assistance services (CDPAS) to 24 hours a day, seven days a week (split shift), for a total of 168 hours a week. The health plan approved consumer directed personal assistance services (CDPAS) 56 hours per week.
Uniform Assessment System (UAS) evaluation completed 6 months ago shows total dependence with shopping; extensive assistance with bathing, personal hygiene, dressing, and toilet use; limited assistance with walking, locomotion and toilet transfer; and supervision with bed mobility and eating. She has bowel and bladder incontinence. A letter from the Provider notes the patient is confused and disoriented. She has been found wandering at least once a month. She needs assistance with activities of daily living. She has gait instability and has had multiple falls. An appeal statement from New York State notes the patient needs assistance with activities of daily living, including toileting multiple times per night. A night log shows need for assistance with toileting every two to three hours.

The proposed treatment is 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. 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 aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions. She is appealing the denial of an increase in consumer directed personal assistance service (CDPAS) to 24 hours a day, seven days a week (split shift), for a total of 168 hours a week. The health plan approved consumer directed personal assistance services 56 hours per week. Uniform Assessment System (UAS) evaluation completed six months ago shows the patient requires assistance with all activities of daily living, except bed mobility and eating. Appeal statements support the patient's need for assistance with activities of daily living. Care logs show the patient requiring care every two to three hours, including care for toileting. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved consumer directed personal assistance services 56 hours per week is insufficient to meet the patient's needs for assistance with activities of daily living and personal care. The proposed 24 hours a day, seven days a week (split shift), for a total of 168 hours a week is medically necessary.