Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease, Osteoarthritis, Spinal Stenosis.

Treatment: Consumer Directed Personal Assistance Services (CDPAS) to split shift 24 hours (two 12-hour shifts) for a total of 168 hours.

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS) to split shifts 24 hours (two 12-hour shifts) for a total of 168 hours.

The denial is modified.

This is a patient with chronic medical problems including Parkinson's disease, osteoarthritis, and spinal stenosis. The patient lives with their daughter, who "assists the patient with daily activities of daily living (ADLs)/instrumental activities of daily living (IADLs)." The insurer approved Consumer Directed Personal Assistance Services (CDPAS) 56.5 hours over 7 days and the request is for an increase in CDPAS to split shifts 24 hours (two 12-hour shifts) for a total of 168 hours.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as independent. The patient is "self-directing, able to make needs known, and communicates well." The patient is reportedly totally dependent on performing much of their Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient is also reportedly totally dependent on bathing, personal hygiene, eating, dressing, and bed mobility. Activities such as locomotion, toilet transfer/use, and ambulation "did not occur." The patient was described as "bed-bound." The patient is reportedly incontinent of bladder and bowel. There has been no change in the patient's ADL status or reported falls over the prior 90 days. 

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require increasing CDPAS 7 days per week, 24 hours per day (split shift). However, the patient does have multiple impairments and functional deficits that support an increase in CDPAS. Based on the clinical records, attention to the patient's functional needs is more appropriately provided and maintained by increasing CDPAS to 84 hours/week.

The healthcare plan did not act reasonably, 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).

From a physical medicine and rehabilitation perspective, an increase in Consumer Directed Personal Assistance Services (CDPAS) to split shifts 24 hours (two 12-hour shifts) for a total of 168 hours is not medically necessary. However, increasing CDPAS to 84 hours/week is medically necessary.

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in Consumer Directed Personal Care Services (CDPAS) to split shift 24 hours (two 12-hour shifts) for a total of 168 hours is not substantiated. However, increasing CDPAS to 84 hours/week is medically necessary.