Diagnosis: Diabetes, heart disease, heart failure, hypertension, hyperlipidemia, osteoarthritis, benign prostatic hypertrophy (BPH), and glaucoma
Treatment: Consumer Direct Personal Aide Service (CDPAS) 7 days x 12 hours x 2 shifts
The insurer denied coverage for CDPAS 7 days x 12 hours x 2 shifts
The denial is overturned in part

The patient is of advanced age and has chronic medical problems including diabetes, heart disease and glaucoma. He lives alone in a private residence. The caregiver is his grandson. Under review is the requested increase CDPAS 7 days x 12 hours x 2 shifts.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is described as "minimally impaired." He refuses to use his Personal Emergency Response System (PERS). However, he is "able to call his daughter in case of emergency." The patient requires extensive assistance for bathing/dressing and limited assistance for personal hygiene. He is independent for toilet transfers and limited assistance for toilet use. He is frequently incontinent of bladder and infrequent of bowel. The patient is independent with bed mobility and transfers. He is able to ambulate with a cane. His gait is unsteady, and he has fallen several times. He was hospitalized after a recent fall. He currently has CDPAS 53 hours/week. The combination of the patient's modest cognitive deficits, and modified independence with functional mobility do not support the medical necessity of the requested CDPAS increase 7 days x 12 hours x 2 shifts. However, his recent functional status decline and multiple falls which included Emergency Room visits and hospitalization, support an increase CDPAS to 84 hours (12 hours/day, 7 days/week); allowing the patient the ability to continue living safely at home.

The healthcare plan acted reasonably in part. From a physical medicine and rehabilitation perspective, the requested CDPAS 7 days x 12 hours X 2 shifts, is not medically necessary. However, a CDPAS increase to 84 hours (12 hours/day, 7 days/week) is medically necessary.

The insurer's denial of coverage for Consumer Direct Personal Aide Service (CDPAS) 7 days x 12 hours x 2 shifts is modified. Medical Necessity is not substantiated for 12-hour split shift/7 days a week. However, 12 hours/day 7 days a week is medically necessary.

The insurer's denial of coverage for Consumer Direct Personal Aide Service (CDPAS) 7 days x 12 hours x 2 shifts is modified as noted above.