Diagnosis: Confusion
Treatment: CDPAS 24 hours a day, 7 days a week live-in totaling 91 hours
The insurer denied the CDPAS 24 hours a day, 7 days a week live-in totaling 91 hours.
The determination is overturned.

This is a female patient with a medical history notable for dementia, incontinence, and arthritis. The patient was approved for 24 hours per day, 7 days per week (live-in) consumer directed personal assistance services (CDPAS) (totaling 91 hours per week). The plan decided to reduce the CDPAS hours to 70 hours per week. The patient and her care team are appealing the reduction in hours.
The patient's physician provided a letter of support for this appeal. The letter states that the patient needs assistance with all activities of daily living, "which requires the patient to have 24-hour home care services." The letter reviews the patient's list of medical conditions.
The patient's case workers provided a letter of support for this appeal. The letter states that the patient cannot use the bathroom without assistance, but due to her dementia she attempts to do so anyway. She will then be found on the floor by her aide in the morning, and will require a change of clothes due to soiling from incontinence.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference. The patient lives alone in her apartment. She was alert and oriented to person only. She recognizes only a few family members. She is confused and unable to direct her own care. For her Instrumental activities of daily living (IADLs), she requires total dependence or maximal assistance for all. For her activities of daily living (ADLs), she requires maximal assistance for bathing, dressing lower body, toilet transfer, and toilet use. She requires extensive assistance for all others. She is frequently incontinent of urine and occasionally incontinent of stool. A task tool associated with the assessment recommended 66 hours per week to address her personal care needs. At issue is the medical necessity of Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day, 7 days a week live-in totaling 91 hours.

The requested health service of CDPAS 24 hours a day, 7 days a week live-in totaling 91 hours is medically necessary for this patient.
The patient has advanced dementia and incontinence. She is not able to ask for help or direct her own care. She requires hands-on assistance for all ADL's and IADL's. Her care needs are expected to be continuous throughout the day and extend into the night at times as well. Given the continuous and unscheduled nature of her needs, the patient requires around-the-clock care with a live-in personal care aide. The additional hours are not solely for the purposes of safety monitoring and supervision, but to assist with her unmet personal care needs. The documentation notes that her nighttime toileting needs are not being met, which places her at risk for adverse health outcomes.