Diagnosis: diabetes mellitus, dysthymic disorder, hypertension, coronary artery disease, asthma, dizziness, insomnia, dementia, urinary incontinence and osteoarthritis.
Treatment: Increase Consumer Directed Personal Care Assistance from 84 hours/week to 24 hours/day, seven days/week (split shift)
The insurer denied the Increase Consumer Directed Personal Care Assistance from 84 hours/week to 24 hours/day, seven days/week (split shift).
The denial is overturned.

Yes, the proposed treatment of an increase in Consumer Directed Personal Care Assistance to 24 hours/day, seven days/week (split shift) is deemed medically necessary.

The patient is a female with a history of diabetes mellitus, dysthymic disorder, hypertension, coronary artery disease, asthma, dizziness, insomnia, dementia, urinary incontinence and osteoarthritis. Due to impairments from her multiple medical issues, she requires assistance for completion of the majority of her activities of daily living (ADLs).

Since the time of her last in home assessment, the patient has been hospitalized twice for recurrent syncopal episodes, dizziness and dyspnea with accidental falls. Further cardiac workup has revealed the presence of severe aortic stenosis for which she underwent an aortic valve replacement surgery. Due to her worsening functionality, recurrent syncopal episodes, dizziness and dyspnea with accidental falls; the currently approved plan of 84 hours/week Consumer Directed Personal Care Assistance is insufficient to meet the patient's current needs. Hence, the proposed treatment of an increase in Consumer Directed Personal Care Assistance to 24 hours/day, seven days/week (split shift) is deemed medically necessary to offer increased support and ADL assistance.