Diagnosis: Coronary artery disease, congestive heart failure, dementia
Treatment: Consumer Directed Personal Assistance Services level II, 2/12 hours per day, seven days per week (split-shift)

The insurer denied Consumer Directed Personal Assistance Services level II, 2/12 hours per day, seven days per week (split-shift). The denial is overturned.

The proposed treatment of an increase in consumer directed personal assistance services level II, to 2/12 hours per day, seven days per week (split-shift) is deemed medically necessary.

The patient is a female with a history of coronary artery disease, congestive heart failure, diabetes mellitus and dementia. Due to restrictions/limitations related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of an increase in consumer directed personal assistance services level II, to two 12 hours per day, seven days per week (split-shift) to offer increased assistance with completion of the patient's ADLs.

This is a female with a history of coronary artery disease, congestive heart failure, diabetes mellitus and dementia. Due to restrictions/limitations related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Although an in home assessment of the patient's functionality and need for ADL assistance was completed; there is more recent documentation from the patient's attending physician. In this correspondence, the provider notes that the patient has demonstrated progressively worsening functional decline secondary to worsening dementia with significant safety concerns involving wandering behavior, turning on the kitchen stove and forgetting to turn it off and increased gait ataxia with frequent falls. For these reasons, the currently approved plan of consumer directed personal assistance services level II 44 hours/week is insufficient to meet the patient's current needs. Hence, the proposed treatment of an increase in consumer directed personal assistance services level II, to 2/12 hours per day, seven days per week (split-shift) is deemed medically necessary.