Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left leg fracture
Treatment: Requested Increase in Consumer Directed Personal Assistance Program (CDPAP) Services: Total Amount of 70 Hours per Week
The insurer denied the Requested Increase in Consumer Directed Personal Assistance Program (CDPAP) Services: Total Amount of 70 Hours per Week .
The determination is overturned.


The patient has a past medical history of coronary artery disease, transient ischemic attack (TIA), recurrent falls, multiple concussions, anxiety, depression, glaucoma, osteoarthritis, hypertension, gastroesophageal reflux disease (GERD), paraplegia, bladder incontinence, and diabetes mellitus with neuropathy who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 56 hours/week based on a telephone assessment assessing the patient at total assistance with task of ordinary housework and maximum assistance with tasks of meal preparation, managing finances, managing medication, shopping, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of phone use, stairs, transportation, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. Notes from the assessment stated the patient had a burn injury to his shoulders and arms in an accident and cannot lift his arms. In addition, notes from this assessment indicated the patient's child and spouse were informal helpers. Notes also stated the patient was supported to get on and off the toilet and uses weightbearing helps to transfer from toilet.
The patient saw his primary care physician (PCP) with the office notes indicating that the patient needed more help with activities of daily living (ADLs). The patient had a fall with left fibular fracture. The patient saw an orthopedic provider in follow-up noting the patient was allowed to start to weight-bear. There was a request to increase the CDPAP services and the patient underwent another telephonic assessment tool assessing the patient at total assistance with ordinary housework and managing finances while maximum assistance with tasks of meal preparation, managing medication, phone use, shopping, transportation, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at extensive assistance with tasks of personal hygiene, dressing upper body, bed mobility, and eating. Notes from the  assessment stated that the patient lived alone and was having an increase in anxiety and panic attacks. The notes also stated the patient required additional assistance with ADLs due to confusion, weakness, recent falls and recent leg fracture, had deterioration in overall self-sufficiency due to recent falls, had onset of incontinence and recent leg fracture, required pre-poured medications, required significant weightbearing assistance for transferring and toileting, needed assistance with cleaning after toileting and adjusting clothing and changing pull-ups, and required significant weightbearing assistance for walking and locomotion.
The insurer sent an initial adverse determination denial notice denying the request to increase CDPAP services. The insurer sent a final adverse determination denial notice also denying request to increase CDPAP services stating the request was not medically necessary and the patient did not meet criteria. The denial stated that the patient's personal care needs can be met with the current hours of 8 hours/day/7 days/week to total 56 hours/week. In addition, the denial stated that granting additional hours was not provided when tasks were not being done and for safety monitoring and supervision.
The patient's PCP provided a letter stating the patient needed 12 hours of personal care aides per day. The patient's healthcare advocate provided a letter requesting an external appeal of denial of increase in CDPAP service hours. At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP) Services: Total Amount of 70 Hours per Week.
The services are medically necessary.
The patient had documented worsening of cognitive and functional status following a fall with a fibular fracture with worsening urinary incontinence and cognitive impairment. The patient's telephonic assessment tool  showed an increase in assistance needs with tasks of managing finances, phone use, stairs, transportation, walking, locomotion, transfer toilet, and toilet use. The patient lives alone which was a change from his prior assessment. The patient required at least extensive assistance with all ADLs/ Instrumental activities of daily living (IADL). The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The request for increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient no longer had a spouse for informal support according to the assessment. The current hours and/or adaptive equipment and/or medical supplies are not sufficient to meet the patient's care needs. The patient's PCP noted a need for 12 hours of assistance per day. 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 10 hours/day, 7 days/week, to total 70 hours/week are medically necessary for this patient. Personal care services are medically necessary under when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.