Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke.

Treatment: for consumer-directed personal aide service (CDPAS) 7 days x 24 hours split shift).

The insurer denied coverage for consumer-directed personal aide service (CDPAS) 7 days x 24 hours split shift).

The denial is modified.

The patient has chronic medical problems including atrial fibrillation, hypertension, and prior stroke. The patient had been living alone in a 2-bedroom apartment. The patient was recently hospitalized after a fall at home and a brain magnetic resonance imaging (MRI) scan demonstrated a left frontal subacute stroke. The patient is currently residing in a skilled nursing facility for rehabilitation and plans to return to her private residence. The insurer approved consumer-directed personal assistance services (CDPAS) 74 hours per week (5 days x 12 hours and 2 days x 7 hours). The request is for CDPAS 24 hours a day, 7 days a week (split shift), totaling 168 hours per week, leading to an external review. 

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." The patient is reportedly totally dependent on completing Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient is also reportedly totally dependent on bathing. Maximal assistance is reportedly needed for personal hygiene, dressing, locomotion, toilet transfer/use, and ambulation. Extensive assistance is reportedly needed for bed mobility and eating. The patient is reportedly frequently incontinent of bladder and bowel. The patient's activities of daily living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. There were also 2 or more falls reported over the prior 30 days. The patient's cognitive and functional status have significantly declined when compared to the UAS report. 

The patient was more recently hospitalized after a fall at home. A subsequent brain MRI scan demonstrated a left frontal subacute stroke. When seen by the neurologist, the patient was described as fully alert and oriented with normal cognitive status; "Attention and concentration normal. Recent and remote memory intact." There was only mild right-side weakness "5-/5." 

The physical therapy discharge summary from the Acute Rehabilitation Center was reviewed. The therapist noted the patient "is alert and oriented x3 (person, date and location), able to make simple wants/needs known, can follow simple 1-2 step commands with increased time for processing." The patient required minimal assistance for transfer activities and minimal to moderate assistance for ambulation with a walker. According to the occupational therapy discharge summary, the patient was independent with oral hygiene and grooming, supervision minimal assistance for dressing, and minimal assistance for toileting. The occupational therapist also noted the patient required minimal assistance for transfer activities. The letter from the patient's treating neurologist describing her clinical condition and recommending personal care 24 hours a day, 7 days a week (split shift) was also reviewed. The reviewer compared the doctor's discussion of the patient's reported limited functional ability with the physical and occupational therapy assessments performed the prior week and as discussed above. There is no current UAS to compare with the previous UAS and to resolve the inconsistencies in the patient's status. 

Based on the documents submitted for review, the patient's medical condition and functional ability are not at a level or unpredictable as to require the requested CDPAS 24 hours a day, 7 days a week (split shift), totaling 168 hours per week. Given the patient's cognitive and functional deficits, modestly increasing CDPAS to 12 hours/day, 7 days/week (84 hours/week) is clinically appropriate. The reviewer would agree the patient may benefit from additional monitoring for safety; particularly due to the patient's reported weakness and fall risk. However, personal assistance services (PAS) hours are approved primarily to provide hands-on assistance for the completion of IADL/ADL tasks when no one else is available to provide assistance. Again, based on the documents submitted for review, the patient's health and safety are appropriately provided and maintained at home with CDPAS 84 hours/week. The patient also has the option of restructuring and flexibly using the 84 PAS hours weekly to better maintain and meet the patient's functional needs. 

The healthcare plan acted reasonably in part, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, the 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). 

Based on the above, the insurer's denial is modified. 

The medical necessity for consumer-directed personal aide service (CDPAS) 7 days x 24 hours split shift) is not substantiated. However, an increase of CDPAS to 12 hours/7 days a week total of 84 hours/week is medically necessary.