Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibromyalgia
Treatment: Consumer Directed Personal Assistance Program (CDPAP) services, for a total amount of 40 hours per week
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) services, for a total amount of 40 hours per week.
The health plan's determination is upheld.

This is a female patient with a medical history notable for fibromyalgia. The patient is approved for 5.5 hours per day, 5 days per week, for a total of 27.5 hours per week, of consumer directed personal assistance program. The patient and her care team requested an increase to 8 hours per day, 5 days per week, for a total of 40 hours per week. This request was denied by the health plan.
The patient's physician, a specialist in psychiatry, neurology, and sleep medicine, provided a letter of support for this appeal. The letter states that the patient has a seizure disorder, sleep apnea, and radiculopathy. She intermittently gets breakthrough seizures. She is on continuous positive airway pressure (CPAP) for sleep apnea. The physician states that additional home care hours are medically necessary, but no details were provided regarding what personal care needs are not currently being met for the patient.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference. The patient lives at home with her children. She was alert and oriented and able to direct her own care. She has periods of forgetfulness. Recall was two out of three at 5 minutes. For instrumental activities of daily living, the patient requires maximal assistance for meal preparation, housework, and shopping. She requires extensive assistance for transportation, stairs. She requires limited assistance for finances. For her activities of daily living, she requires extensive assistance for bathing and dressing lower body. She requires limited assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. She is frequently incontinent of urine and uses liners and pull-ups to manage episodes of incontinence care. She is continent of stool. A task tool associated with the assessment recommended 4.5 hours per day (22.5 hours per week) to address her personal care needs. Compared to a prior assessment, the patient showed a similar level of function. At issue is the medical necessity of an increase in Consumer Directed Personal Assistance Program (CDPAP) services, for a total amount of 40 hours per week.

The requested health service of increase in your Consumer Directed Personal Assistance Program (CDPAP) services, for a total amount of 40 hours per week has not been demonstrated to be medically necessary for this patient.
The patient is currently receiving consumer directed personal care hours which are commensurate with the recommendation by the task tool; she receives one additional hour per day above what is recommended by the tool. There is no documentation regarding which personal care needs, if any, are not being met by the current allotment of personal care hours. The physician letter states that additional hours are medically necessary, but there is no explanation or discussion regarding unmet personal care needs. Therefore, the requested increase has not been demonstrated to be medically necessary for the patient.