Diagnosis: Alzheimer's dementia, dizziness, memory loss
Treatment: Increase Consumer Directed Personal Assistant (CCPAS) to 24 Hours per Day, Split Shift
The insurer denied: Increase Consumer Directed Personal Assistant (CCPAS) to 24 Hours per Day, Split Shift.
The denial is overturned.

This elderly female has conditions including Alzheimer's dementia, hypertension, hypothyroidism, right hand weakness, dizziness, memory loss, and is status post right hip fracture. She is appealing denial of increase in consumer directed personal assistant (CDPAS) to 24 hours per day, split shift. The health plan approved an increase to 70 hours per week. A letter from the provider notes the patient is homebound and bedbound. She needs assistance throughout day and night, to include assistance with ambulation, toileting, transferring, and turning/repositioning. The letter notes an aide cannot sleep for five consecutive hours. A letter from another Provider notes the patient has cognitive and physical limitations as well as dementia. Additional home assistance is recommended. Medical records are provided supporting the patient's chronic conditions.

The proposed treatment is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions. She is appealing denial of increase in consumer directed personal assistant (CDPAS) to 24 hours per day, split shift. The health plan approved increase to 70 hours per week. The appeal statements support the patient is dependent with all activities of daily living and requires frequent assistance with toileting, transfers, and turning/repositioning. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved consumer directed personal assistant 70 hours per week is insufficient to meet the patient's needs. The proposed consumer directed personal assistant 24 hours per day, split shift, is medically necessary.