Diagnosis: major neurocognitive disorder

Treatment: consumer directed personal assistance services (CDPAS) of 24 hours per day, split shift (12 hours x 2 shifts), 7 days per week

The insurer is denied coverage for consumer directed personal assistance services (CDPAS) of 24 hours per day, split shift (12 hours x 2 shifts), 7 days per week

The denial is upheld.

This female patient has a history of Alzheimer's dementia with behavioral disturbances, major depressive disorder, panic disorder, major neurocognitive disorder, bilateral hearing loss, chronic insomnia, astigmatism, cataracts, vitamin B 12 deficiency, vitamin D deficiency, orthopnea, multiple falls, essential hypertension, diabetes mellitus, hyperlipidemia, primary osteoarthritis, mild persistent asthma, functional dyspepsia, chronic constipation, chronic migraines and osteopenia.

She is totally dependent for ordinary housework. The patient needs maximum assistance with meal preparation, managing finances, managing medications, phone use, managing stairs, shopping and transportation. She needs extensive assistance with bathing, personal hygiene, dressing her upper and lower body, walking, locomotion, toilet transfer and toilet use. The patient uses an assistive device for locomotion. It was noted that the patient has frequent falls, and there was one fall reported in the last 30 days. It was also noted that the patient wanders. She needs supervision with bed mobility and limited assistance with eating.
The patient is infrequently bladder incontinent but is bowel continent.
The patient has infrequent urinary incontinence. There is no skin breakdown. She can make her needs known. There is no documentation supporting the need for nightime turning and positioning . The plan has offered to do a sleep study of the patient to determine if in fact an aide would need to be constantly awake in order to provide covered services; these would need to be beyond supervision only. She would then qualify for split-shift. This was refused by the family.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the consumer directed personal assistance services (CDPAS) of 24 hours per day, split shift (12 hours x 2 shifts), 7 days per week is upheld. The medical necessity is not substantiated.