Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impaired Cognition
Treatment: Increase in Consumer Directed Personal Assistance Program (CDPAP) Services: Total of 80.5 Hours per Week [11.5 Hours per Day, 7 Days per Week]
The insurer denied an increase in consumer directed personal assistance program (CDPAP) services: total of 80.5 hours per week [11.5 hours per day, 7 days per week]..
The determination is overturned.

The patient has a past medical history of coronary artery disease, pulmonary embolism, peripheral artery disease, Alzheimer's disease, hypertension, diabetes mellitus type 2, hyperlipidemia, foot ulcer, urinary incontinence and bowel incontinence who had been assigned consumer directed personal assistance program (CDPAP) services 8-1/2 hours/day, 7 days/week, to total 59.5 hours/week based on an assessment tool performed over the telephone. At this assessment the patient was assessed at total assistance with the tasks of meal preparation, ordinary housework, managing finances, managing medication, and shopping while maximum assistance with tasks of phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, and toilet use. The patient was assessed at extensive assistance with tasks of walking, locomotion, transfer toilet, bed mobility, and eating. Notes from the assessment stated the patient required assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) due to severe cognitive impairment and had pain in the lower extremities related to neuropathy and peripheral vascular disease.

The patient was hospitalized with a left heel gangrenous ulcer, myocardial infarction (MI) with 100% occlusion of the right coronary artery (RCA) with a plan for medical management, and pulmonary embolism with placement of an inferior vena cava (IVC) filter. There was a request to increase personal care assistant (PCA) services and the patient underwent a telephonic assessment tool assessing the patient at total assistance with meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, transportation, bathing, dressing lower body, and locomotion while maximum assistance with the tasks of phone use, personal hygiene, dressing upper body, walking, transfer toilet, and toilet use. The patient was assessed at extensive assistance with tasks of bed mobility and eating. Notes from the assessment stated the patient's cognitive skills were severely impaired and she had a fall when going to the bathroom. In addition, this assessment stated the patient had a recent MI, Alzheimer's disease and pulmonary embolism with generalized weakness. The assessment also noted the patient required significant weightbearing assistance as she transferred on and off the toilet and significant weightbearing assistance as she managed her toileting needs.

The patient was seen by her medical provider for hospital follow-up. The insurer sent an initial adverse determination denial notice denying the request for increased PCA services. The patient was seen by her geriatrician noting increased care needs since a prolonged complicated hospitalization, recommendation for increase in home health aide hours, and scored 8 out of 30 on Montreal Cognitive Assessment (MOCA) testing.

The patient's geriatric and palliative care provider sent a letter noting the patient's medical diagnoses and a greater level of debility and dependence with all activities of daily living since her recent hospitalization. The letter further stated the patient required hands-on assistance when going from sit to stand and ambulating, was at high risk for falls due to gait instability, required assistance with toileting as she was unable to properly clean herself, had to be checked multiple times a day for soiling due to her impaired cognition, and could not be placed on a toileting regimen due to her dementia. Lastly, the provider noted the patient has had poor oral intake with unintentional weight loss and required assistance with eating and was recommended to have 12 hours of home care services daily.

The insurer sent a final adverse determination denial notice denying request for increased CDPAP services stating the request was not medically necessary and the patient did not meet criteria. The denial further stated the patient lived with her daughter who was supportive and involved in her care, had a bedside commode, cane, shower chair, shower grab bar, walker, wheelchair and incontinence supplies in her home to assist her with personal care needs, was receiving social daycare in-home services with meals 3 days a week, and the patient's personal care needs could be met with current CDPAP services. The patient was seen in follow-up by urology for a right perinephric hematoma and was felt to be asymptomatic and stable. The patient's geriatrician provided a letter requesting an expedited appeal for the denial of services. The letter stated the patient's current hours are substandard and do not allow for proper support and assistance throughout the day. In addition, the letter stated the patient requires nutritional support, assistance with toileting during episodes of fecal and urinary incontinence, bathing after these episodes with surveillance for further incontinence, required redirection, and her family's work schedules hinder their ability to provide care after the home health aide leaves for the day. At issue is the medical necessity of an increase in consumer directed personal assistance program (CDPAP) services: total of 80.5 hours per week [11.5 hours per day, 7 days per week].

The services are medically necessary.

The patient has documented progressive medical diagnoses of Alzheimer's dementia, urinary and bowel incontinence, and a high fall risk. There has been documentation in the medical record of a decline in functional and cognitive status since her hospitalization. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's current CDPAP service hours and/or adaptive equipment and/or medical supplies are not sufficient to meet all of her care needs. The patient's family is unable to provide care the entire time the personal care assistant is not available and the patient has assistance needs with all ADLs. The increase in CDPAP service hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/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 11.5 hours/day, 7 days/week, to total 80.5 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.