Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure, cerebral vascular accident, cataracts
Treatment: Increase Consumer Directed Personal Assistance Services to 24 Hours per Day, 7 Days per Week (Split Shifts)
The insurer denied: Increase Consumer Directed Personal Assistance Services to 24 Hours per Day, 7 Days per Week (Split Shifts)
The denial is partially overturned.

This patient is an adult female who has conditions including heart failure, implantable cardioverter defibrillator (ICD), chronic obstructive pulmonary disease (COPD), hypertension, diabetes, cataracts, depression, and history of cerebral vascular accident (CVA). She is appealing denial of an increase in consumer directed personal assistance services to 24 hours per day, seven days per week (split shifts). The health plan approved 35 hours per week. She reports a change in her ability to performed daily activities. 

Uniform Assessment System (UAS) evaluation earlier this year shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation and shopping; extensive assistance with managing finances and medications, phone use, bathing, and lower body dressing; and limited assistance with personal hygiene, upper body dressing, walking, locomotion, toileting, bed mobility; and eating. She ambulates with a rollator. She has bowel and bladder incontinence.  Compared to Uniform Assessment System (UAS) evaluation completed 2 months prior, there has only been a decline with ability to perform housework.

A statement from her provider notes the patient has several chronic conditions. She is wheelchair bound. She requires constant care. There are several clinical records provided for review.

The proposed increase in consumer directed personal assistance services to 24 hours per day, seven days per week (split shifts) is not medically necessary; however, an increase to 12 hours per day 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.

This patient has multiple chronic medical conditions. The health plan approved 35 hours per week. Uniform Assessment System (UAS) evaluation completed earlier this year shows the patient needs assistance with all activities of daily living (ADLs). She has bowel and bladder incontinence. Compared to Uniform Assessment System (UAS) evaluation completed 2 months prior, there has only been a decline with ability to perform housework. Clinical records and an appeal statement from the patient's provider have been submitted. The appeal statement notes the patient has several chronic conditions and requires constant care. The information provided does not support that the patient has continuous needs, such as toileting, transfers, and turning/repositioning. Consumer directed personal assistance services (CDPAS) are not indicated for management of chronic medical conditions or for supervision. Therefore, the increase in consumer directed personal assistance services hours from 35 hours per week to 24 hours per day, seven days per week (split shifts) is not medically necessary. However, the approved consumer directed personal assistance services 35 hours per week is insufficient to meet this patient's needs for assistance with all activities of daily living (ADLs). An increase in consumer directed personal assistance services hours to 12 hours per day is recommended to meet this patient's needs throughout the day.