Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic Prostate Cancer 
Treatment: Increase in Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day - 7 Days per Week, 12 Hours per Day - 7 Days per Week (Split Shift) - a Total of 168 Hours per Week

The insurer denied the Increase in Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day - 7 Days per Week, 12 Hours per Day - 7 Days per Week (Split Shift) - a Total of 168 Hours per Week.
The denial is overturned.

The patient has a past medical history of metastatic prostate cancer, diabetes mellitus type 2, hypertension, congestive heart failure (CHF), sleep apnea, hyperthyroidism, chronic obstructive pulmonary disease (COPD), dementia, chronic kidney disease, idiopathic pulmonary fibrosis, urinary incontinence, bowel incontinence, obesity, anxiety, depression, and cirrhosis who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 24 hours/day, live-in, 7 days/week based on previous assessment tools. He was assessed at maximum assistance with tasks of meal preparation, ordinary housework, managing finances, and managing medication while extensive assistance with tasks of stairs, shopping, transportation, bathing, personal hygiene, and dressing upper/lower body. The patient was assessed at limited assistance with tasks of equipment management, walking, locomotion, transfer toilet, toilet use, and bed mobility while supervision with task of eating. With the task of phone use the patient was assessed as independent. On the next assessment tool, the patient was assessed at total assistance with tasks of ordinary housework and locomotion while maximum assistance with tasks of meal preparation, managing finances, managing medication, stairs, transportation, and equipment management. The patient was assessed at extensive assistance with tasks of bathing, personal hygiene, dressing upper/lower body, walking, transfer toilet, toilet use, and bed mobility. With the task of eating and phone use the patient was assessed at limited assistance. The patient had an office visit with his primary care physician (PCP) noting due to the patient's multiple medical problems, use of oxygen (O2), being wheelchair bound, the patient needed extra help and assistance and a request for increased CDPAP services was made. The patient underwent another assessment tool assessing him at total assistance with tasks of meal preparation, ordinary housework, managing finances, shopping, equipment management and locomotion while maximum assistance with tasks managing medication, phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, transfer toilet, toilet use, and bed mobility. With the task of eating the patient was assessed at extensive assistance. Notes from the assessment stated that the patient had a decline in functionality and self sufficiency and had an increased amount of help needed for bathing, dressing upper/lower body, grooming, using the toilet, walking, transferring, eating, moving in bed, prepping meals and managing O2 tubing. The assessment also noted the patient could only take a few steps with walker and was mainly using the wheelchair being pushed by others. In addition, the notes stated the patient needed significant weight bearing assistance to clean himself and adjust clothing after using the toilet.
The plan sent an initial adverse determination notice stating the request for increased CDPAP services hours was not medically necessary. The plan sent a final adverse determination notice stating denial to requested increase to CDPAP services to 24 hours/day, split-shift, 7 days/week as not medically necessary and the patient did not meet criteria. The denial notice stated the patient was not bed bound and there were no Medical Doctor (MD) orders for wound care or turning and positioning, so the criteria for split shifts is not met. Overnight logs were provided noting the patient needed assistance with activities of daily living (ADLs) at least every 2-4 hours.
The patient's provider appealed the denial decision. The patient's oncology provider wrote a letter stating the patient has stage IV metastatic prostate cancer being managed by androgen deprivation therapy. The letter also stated the patient was wheelchair bound, was oxygen dependent, has urinary and bowel incontinence, requires assistance with toileting, needs assistance with meal preparation, needs prompting to eat, and assistance with bathing, dressing, grooming, and housework. The letter further stated the patient would benefit from split-shift assistance given his needs throughout the night, the need for frequent turning and repositioning given his limited mobility and obesity to prevent skin breakdown and pain, that due to overlapping medical comorbidities it is difficult for his family to manage alone, that control of his cancer relies on the patient's ability to correctly take his medication which he needs assistance with, and be able to be assisted with transport to medical appointments. The oncology provider's letter also stated he was concerned that without adequate assistance the patient would not be able to maintain good quality of life and good control of his prostate cancer and strongly believed it was medically necessary for the patient to receive 24 hours/day, split-shift, 7 days/week home aide assistance. The patient's health care advocate provided a letter stating the patient lives with his daughter and granddaughter, his medical diagnoses with recent diagnosis of metastatic prostate cancer, and the patient's decline in function as noted on his plan assessments and his medical provider follow up visits. The advocate further notes split-shift coverage does not only require patient to be bedbound or require turning and repositioning and the patient's overnight needs would not allow an aide to obtain five hours of uninterrupted sleep.
At issue is the medical necessity of an Increase in Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day - 7 Days per Week, 12 Hours per Day - 7 Days per Week (Split Shift) - a Total of 168 Hours per Week.
The services are medically necessary. The patient has documentation of cognitive and functional decline due to his chronic medical conditions. He has unpredictable and unscheduled care needs in the overnight hours that require the assistance of CDPAP aide. Overnight logs show that the patient has ADL assistance needs every 2-4 hours which would not allow a CDPAP aide to obtain at least 5 hours of uninterrupted sleep. The patient's oncology provider documented medical necessity for increase in CDPAP services to 24 hours/day, split-shift, 7 days/week. The increase in CDPAP hours is not solely for safety and supervision but to assist the patient with the safe completion of ADLs/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, CDPAS services 24 hours/day, split-shift, 7 days/week, to total 168 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 his own home.