Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia

Treatment: Consumer directed personal assistance services (CDPAS), 24 hours per day, 7 days a week, split-shift

The insurer denied coverage for consumer directed personal assistance services (CDPAS), 24 hours per day, 7 days a week, split-shift

The denial is overturned

This is a patient with chronic medical problems including hypertension, cerebrovascular accident (CVA) and diabetes. The patient lives alone in a 2 bedroom apartment. The insurer approved Consumer Directed Personal Assistance Services (CDPAS) 63 hours/week and the request is for CDPAS 24 hours a day, 7 days a week (split shift), totaling 168 hours per week.

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as moderately impaired. The patient is totally dependent to maximal assistance for completing much of their Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, dressing and toilet use. Extensive assistance is reportedly needed for personal hygiene, eating, bed mobility, locomotion, toilet transfer and ambulation. However, "the Registered Nurse (RN) observed the member ambulating slowly with a 2-wheeled walker." The patient also reportedly wakes up in the evening and wanders outside of the home. The patient is reportedly frequently incontinent of bladder and bowel. The patient's IADL status and activities of daily living (ADL) status have reportedly declined and deteriorated, respectively over the prior 90 days. The patient has reportedly fallen over the prior 30 days. 

The "Personal Care Logs" were reviewed. Letters from the patient's treating physician indicates the patient "requires some to total assistance" for IADL and ADL tasks were reviewed. The office visit notes were also reviewed. The clinical records document the patient's chronic medical conditions including diabetes, hypertension and progressive dementia. Unfortunately, the provider neither performs a physical examination nor specific functional assessment. 

The clinical records indicate that the patient has significant ADL issues throughout the day and night.  This is further complicated by the patient hallucinating, wandering frequently to the extent that a police search was needed.  While wandering supports the patient's mobility, the patient's impaired cognition actually makes this in some ways a liability as shown by the patient being found outside. Thus, the requested CDPAS 24 hours a day, 7 days a week (split shift), totaling 168 hours per week is supported. The patient's cognitive and functional status have and will continue to decline.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, CDPAS 24 hours per day, 7 days a week, (split shift) is medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for consumer directed personal assistance services (CDPAS), 24 hours per day, 7 days a week, split shift is substantiated.