Diagnosis: Alzheimer's dementia, incontinence of bowel and bladder, abnormalities of gait and mobility, and hypertension

Treatment: Consumer directed personal assistance services (CDPAS) of 24 hours per day, 7 days per week

The insurer is denied coverage for consumer directed personal assistance services (CDPAS) of 24 hours per day, 7 days per week.

The denial is overturned.

The patient is a female with a history of Alzheimer's dementia, incontinence of bowel and bladder, abnormalities of gait and mobility, and hypertension. She has been receiving consumer directed personal assistance services (CDPAS) 12 hours per day, 7 days per week. An increase to Consumer Directed Personal Assistance Services (CDPAS) of 24 hours live-in a day to 7 days per week 2-12 hours a day (split-shift) is being requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; note:

"(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse."

The provision of diapers is not by itself adequate for prevention of pressure sores changing diapers regularly is also necessary. In this case the provision of assistance with transfers, ambulation and toileting is needed throughout the 24 hours, with safety being an additional benefit. Thus 24 hour split shift is medically necessary. The health plan did not act reasonably in the best interest of the patient.

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance Services (CDPAS) of 24 hours a day, 7 days per week 2-12 hours a day (split-shift) is overturned. Medical Necessity is substantiated.