Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Advanced Alzheimer's, Chronic Vertigo, Failure to Thrive, Dysphagia, Gastroesophageal reflux disease with hiatal hernia, Glaucoma.
Treatment:  Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 days a week; 12 hours per day - 7 day a week (split shift) - a total of 168 hours per week.
The health plan denied Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 days a week; 12 hours per day - 7 day a week (split shift) - a total of 168 hours per week.
The denial is overturned in part.

The patient is a female. Her conditions include advanced Alzheimer's, chronic vertigo, failure to thrive, dysphagia, gastroesophageal reflux disease with hiatal hernia, and glaucoma. Denial of consumer directed personal assistance program (CDPAP), 2 - 12 hours per day, 7 days a week, split shift, for a total of 168 hours per week, is being appealed. The plan approved CDPAP 73.5 hours per week.
The patient's current Uniform Assessment System (UAS) evaluation completed shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, phone use, toilet use, and eating; and maximal assistance with bathing, personal hygiene, dressing, walking, locomotion, toilet transfer; and bed mobility. The patient has bowel and bladder incontinence. She had a recent admission after having been found unresponsive due to a urinary tract infection. Compared to the prior UAS (Uniform Assessment System) evaluation completed, there has been a decline with pain, toilet use, eating, and phone use as well as frequency of incontinence.

A statement from the patient's provider notes that the patient has chronic medical conditions and needs assistance with ADLs (activities of daily living). The patient has been hospitalized multiple times in the past 12 months due to falls that resulted in fractures, altered mental status, failure to thrive and fecal impaction. She needs to be hydrated throughout evening hours and needs to be repositioning a few times during the night. She needs around the clock incontinence care. 

Further records show that the patient was hospitalized earlier with chronic constipation and failure to thrive. She was discharged to rehabilitation and transferred home with home care.

The requested increase in Consumer Directed Personal Assistance Program (CDPAP) to 12 hours per day - 7 days a week; 12 hours per day - 7 day a week (split shift) - a total of 168 hours per week, is medically necessary, in part.

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 consumer directed personal assistance program (CDPAP), 2 - 12 hours per day, 7 days a week, split shift, for a total of 168 hours per week, is being appealed. The plan approved CDPAP (consumer directed personal assistance program) 73.5 hours per week. 

This patient has multiple chronic conditions and is status post recent hospitalization with a urinary tract infection. Uniform Assessment System (UAS) evaluation completed recently shows the patient requires maximal assistance to total dependence with all ADLs (activities of daily living). She is incontinent of bowel and bladder. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline with pain, toilet use, eating, and phone use as well as frequency of incontinence.
The appeal statement supports the patient's need for assistance with ADLs (activities of daily living). The provider notes that the patient's nighttime needs include needs for hydration and repositioning a few times during the night. The information provide show that this patient has significant limitations in functioning. The approved CDPAP (consumer directed personal assistance program) 73.5 hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). However, the documentation does not support that the patient's has a frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. The requested increase CDPAP (consumer directed personal assistance program) to 168 hours per week, split shift is appropriate. Rather, an increase in CDPAP (consumer directed personal assistance program) hours to live-in is medically necessary to meet this patient's needs. CDPAP (consumer directed personal assistance program) live-in is medically necessary to meet this patient's needs.

The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient, in part.  CDPAP (consumer directed personal assistance program) live-in is medically necessary to meet this patient's needs.