Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied an Increase in Consumer Directed Person Assistance Services. 
The denial was overturned. 

The patient is a female with a past medical history of dementia, osteoarthritis, diabetes mellitus type 2, hypertension, smoldering multiple myeloma, urinary incontinence, chronic kidney disease, and osteoporosis who had been assigned 28 hours/week of Consumer Directed Personal Assistance Program (CDPAP) services. The patient saw her primary care physician (or provider) (PCP) with office notes stating the patient's daughter was requesting increased home health hours as the patient recently lost her husband. Assessment and plan from this office visit noted pertinent forms will be filled out and faxed appropriately for request to increase home health aide services. The patient had been hospitalized with a hyperglycemic episode and during hospitalization due to rapidly declining dementia had a palliative care consultation. The patient continued with episodes of agitation and wandering with aggressive behaviors and sundowning and was treated with olanzapine. 
The insurer sent final adverse determination denial notice denying request to increase CDPAP services to 24 hours/day, split shift, 7 days/week but approving CDPAP services 42 hours/week. The denial stated the patient could consider moving into a nursing home for long term care, seek services from the nursing home transition and diversion waiver program, or her informal caregiver could choose to supplement her CDPAP services on an informal basis as to provide constant safety supervision.
At issue is the medical necessity of Increase in Consumer Directed Person Assistance Services; 1 Client; 168 hours/week.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Increase in Consumer Directed Person Assistance Services; 1 Client; 168 hours/week is medically necessary for this patient.
There is documentation from the patient's PCP and palliative care physician of significant functional and cognitive decline following the patient's husband's death and hospitalization. The patient's daughter documents further decline following the patient's COVID-19 diagnosis. The patient requires supervision and limited assistance with tasks of walking, locomotion, transfer to the toilet, and toilet use. The patient's palliative care physician documented bowel incontinence with need for assistance with turning and repositioning as well as incontinence care in the overnight hours. Due to the patient's dementia, she does have sundowning and when ambulating requires assistance to prevent falls and injury. The patient has 24-hour care needs and therefore the assessment tool should not have been utilized to calculate CDPAP hours. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. Due to the patient's assistance needs, a CDPAP aide would be unable to obtain at least 5 hours of uninterrupted sleep. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 168 hours/week are medically necessary for this patient. 
Therefore, the requested health service/treatment of Increase in Consumer Directed Person Assistance Services; 1 Client; 168 hours/week is medically necessary.