Diagnosis: Central Nervous System/Neuromuscular.
Treatment: Home Health Care.
The insurer denied Consumer Directed Personal Assistance Services. 7 days per week, 24 hours per day continuous care by more than one person.
The denial is overturned.

The patient is a female with past medical history of central pontine myelinolysis, type II neuropathy, bedbound status, coronary artery disease, diabetes mellitus type 2, bipolar disorder, hypertension, nephrolithiasis, hyperlipidemia, incontinence of stool, and incontinence of bladder who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 12 hours/day x 7 days/week to total 84 hours/week based on assessment tool performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, equipment management, and locomotion while maximum assistance with tasks of managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, toilet use, bed mobility, and eating. The tasks of walking and transfer toilet did not occur during assessment. The subject under review is the medical necessity for CDPAP services 7 days per week 24 hours a day continuous by more than one person.

The requested service is medically necessary for this patient.
The patient is noted to have a degenerative brain condition with documented decline in physical and mental functioning since hospitalization. The patient is noted to require assistance with all activities of daily living (ADLs)/Instrumental activities of daily living (IADLs). The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer has failed to document a plan to meet these unpredictable and unscheduled care needs especially in the overnight hours. There is documentation that the patient has skin breakdown with the necessity for turning and repositioning as well as changing soiled diapers every 2 to 3.5 hours. Patient's overnight care needs would not allow a CDPAP aide to obtain at least 5 hours of uninterrupted sleep. Furthermore, there is no definite documentation that the patient's new apartment would be able to accommodate a CDPAP aide, live-in. The patient's care needs cannot be met solely with medical supplies and adaptive equipment. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 24 hours/day, 7 days/week, continuous by more than one person are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.