Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional limitations due to multiple medical problems including late effects of a cerebrovascular accident.

Treatment: Consumer Directed Personal Assistance Program (CDPAP) service of 12 hours per day, 7 days per week (split-shift) for a total of 168 hours per week.

The insurer denied coverage for CDPAP service of 12 hours per day, 7 days per week (split-shift) for a total of 168 hours per week.

The denial is overturned. 

This is a male patient with a past medical history of hypertension, hyperlipidemia, coronary artery disease status post coronary artery bypass graft, cerebrovascular accident, prostate cancer, tongue cancer, oropharyngeal dysphagia, chronic osteoarthritis and dementia.  The patient has a diagnosis of late effect cerebrovascular accident.  The patient's nutrition is poor, and he is at high risk for aspiration and is on precautions.  He is noted to be at high risk for falls and had one in the past.  The patient is also lethargic and has increasing periods of confusion at night.  He lives alone in a studio apartment on the 2nd floor of an elevator accessible apartment building.  The patient is noted to have short term and procedural memory problems.  The patient also has bilateral hearing difficulty.  The patient's daughter reported that the patient has anxiety due to his current health conditions.  His condition has declined due to increased weakness, imbalance and fall.  The patient has dyspnea and diminished energy, and he is unable to finish normal day to day activities.  The patient is totally dependent for ordinary housework and managing medications.  The patient needs maximum assistance with meal preparation, managing finances, shopping, transportation, bathing and dressing his lower body.  He needs extensive assistance with managing stairs, personal hygiene, dressing his upper body, walking, locomotion and toilet transfer.  He has daily episodes of urinary incontinence and bowel incontinence every few days.  The patient uses an assistive device for locomotion indoors.  There were no pressure ulcers or foot problems noted.   The patient needs limited assistance with toilet use.  He is independent with eating.  An increase to Consumer Directed Personal Assistance Program (CDPAP) service of 12 hours per day, 7 days per week (split-shift) for a total of 168 hours per week is being requested.

The patient has functional limitations due to multiple medical problems including late effects of a cerebrovascular accident.  He has needed extensive assistance in multiple activities of daily living (ADLs).  He has daily episodes of urinary incontinence and bowel incontinence every few days.  In comparing Uniform Assessment System (UAS) documentation, the patient has gone from limited assistance in bed mobility to extensive assistance.  He needs extensive assistance with ambulation and transfers.  At a recent Physical Therapy (PT) visit, the patient was non-ambulatory with trouble getting from bed to chair with assistance.  Bed mobility is maximum assistance.  At Social Work visits the patient was lethargic and minimally responsive. 

This reviewer disagrees with the health plan.  This reviewer feels they did not sufficiently take into account changes in the patient's condition. The patient's functional status both mentally and physically has changed since his hospitalization for COVID-19.  He has increased need for help with ADLs, most critically with bed mobility, with transfers and ambulation and having incontinence multiple time/day.  He has durable medical equipment but has decreased capacity to function with it.  At this point the safety monitoring is part of the overall increased needs for the patient.

The carrier's denial of coverage for Consumer Directed Personal Assistance Program (CDPAP) service of 12 hours per day, 7 days per week (split-shift) for a total of 168 hours per week is substantiated.  The insurer's denial is overturned.