Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Progressive dementia and severe arthritis with gait
instability
Treatment: Increase Consumer Directed Personal Assistance (CDPAS) From 7 Days Per Week, 7 Hours Per Day, 49 Hours Per Week To 7 Days Per Week, 24 Hours Per Day, Continuous Care by More Than 1 Person; 168 Hours Per Week
The insurer denied the Increase Consumer Directed Personal Assistance (CDPAS) From 7 Days Per Week, 7 Hours Per Day, 49 Hours Per Week To 7 Days Per Week, 24 Hours Per Day, Continuous Care by More Than 1 Person; 168 Hours Per Week
The denial is overturned, in part.

The patient is a female. Her medical conditions include progressive dementia and severe arthritis with gait instability. She is appealing denial of increase consumer directed personal assistance (CDPAS) from seven days per week, seven hours per day, 49 hours per week, to seven days per week, 24 hours per day, continuous care, total of 168 hours per week.

The patient's Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances and medications, and shopping; extensive assistance with phone use, stairs, bathing, lower body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion, eating and toileting; and independent with bed mobility. She is infrequently incontinent of bowel and bladder. Compared to Uniform Assessment System evaluation completed previously, her cognition has deteriorated, and she requires more assistance with managing medications, personal hygiene, dressing, toilet use, and bed mobility.

A statement from the patient's doctor notes the patient has progression of dementia and ability to transfer. She has difficulty getting up from chair and bed. She wakes up four to five times per night, but has difficulty getting to the bathroom. She needs constant hands-on focus, around the clock, because she is a high fall risk.

A statement notes the Uniform Assessment System (UAS) evaluation is incorrect. It states the patient is unable to transfer to standing, sitting or walking without physical assistance. She awakens multiple times during the night to use the toilet. She becomes disoriented during the night and requires hands on assistance to prevent her for trying to get out of the bed. Her sons have been caring for her overnight but are unable to continue.

Yes, in part; the increase in Consumer Directed Personal Assistance is medically necessary, in part. Specifically, the proposed increase in consumer directed personal assistance to seven days per week 24 hours per day continuous care, total of 168 hours per week is not medically necessary; however, an increase in consumer directed personal assistance to live-in 24 hour care 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. Denial of increase consumer directed personal assistance service (CDPAS) from seven days per week, seven hours per day, 49 hours per week to seven days per week, 24 hours per day, continuous care, total of 168 hours per week is being appealed.

This patient has progressive dementia and gait instability. Uniform Assessment System (UAS) evaluation completed shows she requires assistance with all activities of daily living (ADLs), except gait mobility. Compared to Uniform Assessment System (UAS) evaluation completed previously, her cognition has deteriorated, and she requires more assistance with managing medications, personal hygiene, dressing, toilet use, and bed mobility. She is infrequently incontinent of bowel and bladder. Appeal statements note the patient's dementia and physical mobility have deteriorated making her a high fall risk. She requires assistance with all transfers. She awakens multiple times during the night for toilet use, tries to get out of the bed, and becomes disoriented. This patient needs a significant amount of assistance with activities of daily living. Her cognition and physical functioning have declined between Uniform Assessment System evaluations completed.  

Based on the information provided, the approved consumer directed personal assistance service, seven  days per week, seven hours per day, 49 hours per week, is inadequate to meet the patient needs for assistance with activities of daily living and personal care. However, the information provided does not support continuous care. She does not have frequent, one to two hourly needs, such as turning/repositioning. The documentation does not support that an aide is unlikely to get five hours daily of uninterrupted sleep during the aide's shift. The proposed increase in consumer directed personal assistance to seven days per week 24 hours per day continuous care, total of 168 hours per week is not medically necessary. An increase in consumer directed personal assistance to live-in 24 hour care is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient, in part.