Diagnosis: Hypertension, arthritis and dementia.
Treatment: Consumer directed personal assistance services (CDPAS), 7 days per week, 2-12 hours split shift.
The insurer denied coverage for CDPAS, 7 days per week, 2-12 hours split shift.
The denial is overturned.

This is an elderly patient with multiple medical problems including hypertension, arthritis, and dementia. She lives alone. The insurer reduced CDPAS hours from split-shift to live in reportedly due to the patient no longer meeting the criteria for the split shift level of service. The insurer asserts, the patient's live-in CDPAS worker can get 5 hours of continuous sleep, which does not need to happen during the nighttime hours. The patient is requesting reinstatement of CDPAS 7 days per week, 2-12 hours split shift.

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times." She requires maximal assistance for bathing, personal hygiene, dressing, toilet transfers/use. She is frequently incontinent of bowel and bladder. Extensive assistance is needed for bed mobility and eating. The patient's medical condition and essentially total dependence to maximal assistance for instrumental activities of daily living (IADL) and functional needs are at a level or unpredictable as to require the requested personal care aide (PCA) services 24 hours/day, 7 days/week (split shift). Based on the records reviewed, the live-in CDPAS is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. The patient's health and safety was more appropriately provided and maintained at home with the previously approved CDPAS services 24 hours/day, 7 days/week split shift.

From a physical medicine and rehabilitation perspective, CDPAS, 7 days per week, 2-12 hours (split shift) is medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for consumer directed personal assistance services (CDPAS), 7 days per week, 2-12 hours split shift services is substantiated.