Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple medical conditions, including dementia, CVA (cerebrovascular accident) with hemiplegia and hemiparesis, neuralgia, hypertension, insomnia, abnormal gait, osteoarthritis, glaucoma, dizziness, fatigue, and pain. 

Treatment: Increase Consumer Directed Personal Assistance Services from 70 hour per week to 24 hours per day 7 days per week (split shift). 

The insurer denied the request for an increase of Consumer Directed Personal Assistance Services from 70 hour per week to 24 hours per day 7 days per week (split shift). 

The denial is overturned, in part. 

The patient is an adult female who has multiple medical conditions, including dementia, CVA (cerebrovascular accident) with hemiplegia and hemiparesis, neuralgia, hypertension, insomnia, abnormal gait, osteoarthritis, glaucoma, dizziness, fatigue, and pain. 

The patient lives with her daughter, who provides support after service hours.  The daughter is requesting an increase in hours because the patient has difficulty sleeping at night and needs supervision at all times, as well as assistance with ADLs (activities of daily living).  UAS (Uniform Assessment System) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, and shopping; maximal assistance with phone use, bathing, lower body dressing, and toilet use; extensive assistance with stairs, personal hygiene, upper body dressing, walking, locomotion, and toilet transfer; and limited assistance with bed mobility and eating.  The patient is frequently incontinent of bowel and bladder.  She had multiple falls in the prior 90 days. 

An appeal letter notes that the patient's cognitive impairment causes her to forget that she requires assistance when she tries to get up, resulting in several falls during the night.  The appeal letter notes that the patient's need for assistance with the bathroom at night are not being met. The appeal letter  further notes that the frequency of needs at night would not allow an aide to get five hours of sleep. The appeal letter notes that the patient is unable to turn around her own. 

A letter from a physician notes that the patient is wheelchair-bound and unable to perform ADLs (activities of daily living). 

This is an appeal for denial of an increase Consumer Directed Personal Assistance Services, from 70 hours per week to 24 hours per day, 7 days per week, split shift. 

Yes, the increase in Consumer Directed Personal Assistance Services, from 70 hour per week to 24 hours per day 7 days per week (split shift) is medically necessary, in part. 

While an increase in service hours to 24 hours per day, 7 days per week, split shift, is not medically necessary, an increase in service hours to 24 hours per day, 7 days per week, live in, 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 provider five hours daily of uninterrupted sleep during the aide's shift. 

This patient has multiple chronic conditions including dementia.  She lives with her daughter who provides support.  Her daughter is appealing the denial of an increase Consumer Directed Personal Assistance Services, from 70 hours per week to 24 hours per day, 7 days per week, split shift.  The daughter is requesting an increase in hours, because the patient has difficulty sleeping at night and needs supervision. 

UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs / IADLs (activities of daily living / instrumental activities of daily living).  She is incontinent of bowel and bladder.  She has had multiple falls.  Appeal statements note that there has been a decline in the patient's cognition.  The provider states that the patient is wheelchair bound.  The patient attempts to get up without assistance.  Additional hours are recommended to assist with ADLs (activities of daily living) and unscheduled nighttime bathroom needs. This patient requires significant assistance with ADLs / IADLs (activities of daily living / instrumental activities of daily living). 

The currently approved 70 hours per week are not sufficient to meet this patient's needs.  However, PAS (personal assistance service) is not indicated for supervision. The information provided does not support continuous needs with ADLs (activities of daily living) that would prohibit an aide from getting five hours of uninterrupted sleep.  The proposed increase to CDPAS (consumer directed personal assistance service) 24 hours per day, 7 days per week, split shift is not medically necessary.  However, an increase in Consumer Directed PAS (personal assistance service) 24 hours per day, live in, is appropriate and is medically necessary to meets this patient's needs for assistance with ADLs (activities of daily living) and personal care.