Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day-7 days per week; 12 hours per day-7 days per week (split shift) total of 168 hours per week 
The insurer denied Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day-7 days per week; 12 hours per day-7 days per week (split shift) total of 168 hours per week. 
The determination is overturned in part.

This is a male patient with a medical history notable for Alzheimer's dementia, Parkinson's disease, urinary incontinence, arthritis, and diabetes. The patient is approved for 4 hours per day, 5 days per week for a total of 20 hours per week of consumer directed personal assistance care. The patient and his care team requested an increase to 24-Hour per day, 2-12 hour split-shift, 7 days per week for a total of 168 hours per week. This request was denied by the health plan.
The patient's neurologist provided a letter of support for this appeal. The letter states that due to his worsening Alzheimer's dementia, the patient is having increasing difficulty with orientation to time and place. The provider states that the patient requires at least 5 hours per day of assistance.
The patient's primary care physician provided a letter of support for this appeal. The letter states that the patient has dementia and Parkinson's disease. His wife is his primary caregiver and is no longer to assist with his daily needs. He requires a home health aide daily for assistance with activities of daily living for his safety. No further details were provided regarding unmet personal care needs.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient lives in his home with a friend and his wife. His cognition was severely impaired. He was alert but disoriented to all domains. He is not able to direct his own care. His short-term and procedural memory was not intact. His caregiver reported sundowning everyday. For his instrumental activities of daily living, he requires total dependence for all (with the exception of stairs). For his activities of daily living, he requires total dependence for bathing, hygiene, and dressing. He requires limited assistance for walking, locomotion, and toilet transfer. He requires total dependence for toilet use. He requires supervision only for bed mobility and eating. He is frequently incontinent of urine and infrequently incontinent of stool. He wears Pull-Ups for incontinence care. Compared to a prior UAS, he showed a decline in functional and cognitive status. At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day-7 days per week; 12 hours per day-7 days per week (split shift) total of 168 hours per week. 

In part. The requested health service of CDPAP: 12 hours per day-7 days per week; 12 hours per day-7 days per week (split shift) total of 168 hours per week has not been demonstrated to be medically necessary for this patient. 24-hour live-in personal care is medically necessary for the patient. The patient requires assistance for transfers, ambulation, and toileting. He is incontinent of urine and stool. His care needs are expected to be continuous and unscheduled throughout the day and occur occasionally at night as well. Therefore, it is medically necessary and reasonable for him to receive 24-hour live-in personal care, for a total of 91 hours per week.
There is insufficient evidence that the patient requires 24-hour split-shift care. He does not require assistance with bed mobility and does not have pressure ulcers. There are no nighttime care logs which demonstrate a frequency of needs which would preclude a live-in personal care aide from receiving sufficient rest overnight. Personal care aides can only be approved when needed to perform personal care duties, and cannot be approved for supervision or safety monitoring alone in the absence of a personal care task. Therefore, there is insufficient evidence that the request for 24-hour split-shift care is medically necessary for the patient.
 24-hour live-in personal care, 91 hours per week is medically necessary.