Diagnosis: Traumatic brain injury.
Treatment: Consumer directed personal assistance program (CDPAP) 12 hours per day-7 days per week: 12 hours per day- 7 days per week (split shift)- for a total of 168 hours per week.
The insurer denied coverage for CDPAP (split shift)- for a total of 168 hours per week.
The denial is overturned.

The patient had a fall and suffered a traumatic brain injury (TBI). There is a request to increase CDPAP to 12 hours per day- 7 days per week: 12 hours per day 7 days per week (split shift)- for a total of 168 hours per week.

An appeal stated the patient has TBI after having fallen, which renders the patient totally dependent for activities of daily living (ADLs), such as bathing and toileting. The note indicates the patient is unsafe at home without supervision and needs 24-hour-a-day assistance to manage his safety and ADLs. The patient is currently getting 24.5 hours per week.

An assessment indicates that the patient lives with his sister on the third floor, and that he is severely impaired. The patient has knowledge deficit in taking his medications, and the deficit will last more than 120 days. The patient does not recognize family members, is occasionally agitated, and has childlike affect.

The plan offered 3.5 hours per day. Given the severity of the patient disability, a need exists for 24 hour-a-day assistance for this patient.

This individual had been an independent healthy machinist until he fell and injured his brain, for which he now has TBI, rendering him completely dependent for ADLs, as noted by his physician. The patient is noted to have increased weakness and a dramatic cognitive decline, which has resulted in child-like behavior and affect, resulting in unsafe behavior, and a need for increased hours. Given this scenario, the request for CDPAP split shift- for a total of 168 hours per week is medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Consumer directed personal assistance program (CDPAP) 12 hours per day-7 days per week: 12 hours per day- 7 days per week (split shift)- for a total of 168 hours per week is overturned. Medical Necessity is substantiated.