Diagnosis: Dementia.
Treatment: Home health care.
The insurer denied CDPAS (Consumer Directed Personal Assistance Services) - 24 Hours per Day [Split-Shift].
The health plan's determination is upheld.

The patient is a male with past medical history of Alzheimer's dementia, osteoarthritis, anemia, constipation, prostate cancer, and urinary incontinence who had been assigned CDPAS (Consumer Directed Personal Assistance Services) 25 hours/week based on telephonic assessment assessing the patient at total assistance with managing finances while maximum assistance with tasks of meal preparation, ordinary housework, and shopping. With tasks of managing medication, phone use, and transportation, the patient was assessed at extensive assistance while limited assistance with tasks of bathing and dressing lower body. The patient was assessed at supervision with tasks of stairs, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and eating while independent with task of bed mobility. The patient's neurologist provided a letter stating the patient's cognitive status was declining and now required 24 hours of care Monday-Friday and required and increase in home care hours to ensure a safe home environment.

CDPAS (Consumer Directed Personal Assistance Services) - 24 Hours per Day [Split-Shift] are not medically necessary for this patient.

Although there is documentation of deterioration of the patient's cognitive and functional status as well as lack of informal care there is no documentation supporting overnight care needs requiring split shift services. There are no overnight logs documenting assistance needs that would not allow a PCA (personal care assistant) 5 hours of uninterrupted sleep. There is no documentation from the patient's provider that he requires turning and repositioning at least every 2 hours. The requested split shift services would be for safety and supervision without documentation of medical necessity of assistance with activities of daily living (ADL) and Instrumental activities of daily living (IADL) overnight or the need for turning and repositioning every 2 hours. Services for safety and supervision or when the patient doesn't require assistance with ADLs/IADLs are not indicated.
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, CDPAS services 24 hours/day, split-shift, are not medically necessary for this patient.