Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia, Anxiety
Treatment: 40 hours (hrs) per week, consumer directed personal assistant services level 2
The insurer denied 40 hours (hrs) per week, consumer directed personal assistant services level 2.
The determination is overturned.

The patient is a female with a past medical history of schizophrenia, morbid obesity, chronic pain, depression, and anxiety who had been assigned 15 hours of Consumer Directed Personal Assistance Program (CDPAP) services per week based on video assessment performed assessing the patient at total assistance with the tasks of managing finances and managing medication while maximum assistance with the tasks of meal preparation, ordinary housework, shopping, and transportation. With the tasks of stairs, dressing upper/lower body, and transfer toilet the patient was assessed at limited assistance while independent with the tasks of phone use, personal hygiene, walking, locomotion, toilet use, bed mobility, and eating. A tasking tool estimated 10.9 hours per week (hours/week). The patient had an inpatient hospitalization for psychiatric diagnosis and there was a request for an increase in CDPAP services.
The patient underwent a video assessment. A tasking tool estimated 14.2 hours/week.
The insurer sent an initial adverse determination denial notice denying the request to increase Consumer Directed Personal Assistance services (CDPAS) stating based on the most recent assessment, they were unable to increase home care hours and the patient had a choice to use her weekly hours as she wanted and needed throughout the week to cover her service needs. The insurer sent a final adverse determination denial notice continuing to deny request to increase CDPAP services stating the plan did not provide an aide for safety and supervision alone and services were not authorized if needed for assistance could be safely met by medical supplies such as diapers, chalks, commodes, walkers, and wheelchairs. The patient's primary care physician (or provider) (PCP) provided a letter requesting an increase in personal care services as her current hours were insufficient to meet the patient's care needs with a request to increase to 56 hours/week. The provider also noted the patient had medical and psychiatric conditions and was not expected to improve, the patient was homebound and had limited formal or informal support to provide assistance to meet her personal care needs. At issue is the medical necessity of 40 hours (hrs) per week, consumer directed personal assistant services level 2.

Yes, the services are medically necessary. There is documentation from the patient's medical provider of the medical necessity of increased CDPAP services. In addition, there is documentation that the patient has limited informal and formal support and would need assistance outside of the hours she currently has informal and formal support. The patient has assistance needs with toilet use which is an unscheduled and unpredictable care need and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met solely by adaptive equipment and medical supplies. The requested increase in services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and Instrumental activities of daily living (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 40 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.