Appeal type: Medical necessity
Decision: Upheld

Diagnosis: diabetes, hypertension, and osteoarthritis

Treatment: home care/personal care directed personal assistance services (CDPAS) increase to 84 hours per week

The insurer denied coverage for home care/personal care directed personal assistance services (CDPAS) increase to 84 hours per week

The denial is upheld.

 
This is an elderly female with chronic medical problems including diabetes, hypertension, and osteoarthritis.  She lives with her daughter in a private residence.  The insurer approved consumer directed personal assistance services (CDPAS) 70 hours/week (10 hours/day, 7 days/week).  The request is for CDPAS 84 hours/week (12 hours/day, 7 days/week); leading to an external review.

The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as moderately impaired.  She is reportedly total dependent for completing much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient is reportedly total dependent for toilet use.  Maximal assistance is reportedly required for bathing, lower body dressing and toilet transfer.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing, locomotion and ambulation.  Limited assistance is reportedly needed for bed mobility and eating.  The patient is reportedly frequently incontinent of bladder and occasionally incontinent of bowel.  There have been no reported falls over the prior 90 days.  Her ability to perform activities of daily living (ADL) and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. The patient's cognitive and functional ability are much the same when compared to the prior UAS report.

The patient's condition and functional deficits are not at a level or unpredictable as to require the requested increase CDPAS to 84 hours/week.   The letter from the patient's treating physician describing her clinical condition and recommended "increase in homecare services to assure she can safely complete her activities of daily living at all times day and night" was reviewed.  The doctor does not include the associated treatment notes to support his claim of the patient's reported functional incapacity.  There was no documented functional assessment.  

This physician would agree the patient may benefit from additional monitoring for safety; particularly due to her reported wandering, weakness and falls risk.  However, hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no else is available to provide assistance.  The patient also has another adult living in the home who has shared household responsibilities.  Based on the documentation submitted for review, the patient's health and safety are appropriately provided and maintained at home by continuing CDPAS 70 hours/week.   

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for home care/personal care directed personal assistance services (CDPAS) increase to 84 hours per week is not substantiated.