Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness, Difficulty Ambulating
Treatment: Consumer directed personal assistance program (CDPAP) 5 hours per day- 6 days per week- for a total of 30 hours per week.
The insurer denied Consumer directed personal assistance program (CDPAP) 5 hours per day- 6 days per week- for a total of 30 hours per week.
The determination is overturned.

This is a patient with a past medical history of hypertension, anxiety, depression, osteoarthritis, coronary artery disease, diabetes mellitus type 2, obesity, sciatica, gastroesophageal reflux disease (GERD), asthma, and urinary incontinence who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 20 hours/week based on an assessment tool performed assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, stairs, transportation, bathing, and dressing lower body. With the tasks of dressing upper body and bed mobility the patient was assessed at limited assistance while supervision with tasks of managing medication, walking, and locomotion. The patient was assessed at set up only with the task of phone use and independent with the tasks of personal hygiene, transfer toilet, toilet use, and eating. The tasking tool estimated 4 hours/day, to total 20 hours/week.
There was a request to increase CDPAP and the patient underwent another assessment assessing the patient at maximum assistance with the tasks of meal preparation, stairs, shopping, transportation, bathing, and dressing lower body while extensive assistance with tasks of managing finances, managing medication, walking, locomotion, transfer toilet, and bed mobility. With the task of dressing upper body the patient was assessed at limited assistance while set up with task of phone use. The patient was assessed at independent with tasks of personal hygiene, toilet use, and eating. Notes from the assessment stated the patient lived in an apartment with her spouse, had a decline in activities of daily living (ADL) status in the last 90 days and a deterioration in overall self sufficiency in the last 90 days. The tasking tool estimated 5 hours/day to total 25 hours/week.
The insurer sent an initial adverse determination denial notice denying the request to increase CDPAP services stating the patient's current hours were appropriate and safely meeting her personal care needs. The insurer sent a final adverse determination denial notice continuing to deny the request to increase CDPAP services stating the patient was able to direct her own care, the patient had medical equipment in the home, the patient had family who were supportive and involved in her care, and additional hours were not provided when tasks were not being performed and for safety monitoring and supervision. The patient and her family appealed the denial decision. The patient had an office visit with her primary care physician (or provider) (PCP) with the office note stating the patient's medical diagnoses and need for services. At issue is the medical necessity of consumer directed personal assistance program (CDPAP) 5 hours per day- 6 days per week- for a total of 30 hours per week.

The services are medically necessary. There is documentation from the plan's assessments of an increase in assistance needs with tasks of ordinary housework, managing medication, stairs, transportation, bathing, dressing lower body, walking, locomotion, transfer toilet, and bed mobility when comparing the assessments. The plan's assessment also documented a decline in ADL status and a deterioration of overall self-sufficiency. The patient requires at least extensive assistance with walking, locomotion, and transfer toilet and therefore the patient has unscheduled and unpredictable care needs that span a continuum of time but the insurer did not document a plan to meet these needs when the patient does not have informal help. The tasking tool itself showed an increase in hours of services from the previous assessment. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 30 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.