Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Othopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied CDPAP services, 1 client for 168 hours. 
The denial was overturned.

The patient is a female with a past medical history of polymyositis, wheelchair-bound status, and decubitus ulcer who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 24 hour/day, live in, 7 days/week based on assessment tool assessing the patient at total assistance with tasks of ordinary housework, stairs, transportation, bathing, dressing upper/lower body, transfer toilet and toilet use. Maximum assistance with tasks of meal preparation, managing medication, shopping, equipment management, personal hygiene, bed mobility, and eating. The patient was assessed at extensive assistance with managing finances, phone use, and locomotion. The assessment noted the task of walking did not occur. The patient stated she sleeps for 5-6 straight hours during the night.
The insurer sent final adverse determination denial notice denying request to increase CDPAP services again stating there was no documentation provided that showed the patient had nighttime needs or that the patient had made attempts to reduce nighttime urinating such as decreasing fluids before bed, medications to help hold onto the urine, or using a bedside commode. The denial also stated there was no detailed documentation of sleep medications tried or failed or any formal education on sleep hygiene. In addition, the denial stated there was no sleep log submitted that showed the member did not sleep for a 5-hour period at night which would keep the aid from getting 5 hours of uninterrupted sleep.
The patient appealed the denial decision by insurer.
At issue is the medical necessity of Consumer Directed Person Assistance; 1 Client- 168 hours/week.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Consumer Directed Person Assistance; 1 Client- 168 hours/week is medically necessary for this patient.
The patient has severe muscular disease with severe functional disabilities as documented by the universal assessment and the patient's PCP. The universal assessment noted the patient is unable to turn in bed. The PCP letter noted the patient needed overnight coverage especially with turning in bed to relieve pressure from decubitus ulcer. Although the universal assessment noted the patient "sleeps 5 to 6 hours at night" this does not mean she does not need to reposition and change position in bed to prevent worsening decubitus ulcer and new decubitus ulcers. The patient requires total assistance with transfer to the toilet and toilet use as well as bed mobility, and transfers. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer has failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's PCP noted she does not drink enough water because she does not have around-the-clock care and there is no one to help her with her unscheduled and unpredictable care needs. The patient's care needs in the overnight hours are such that a personal care aide would not be able to obtain at least 5 hours of uninterrupted sleep.
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 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 her own home.
Therefore, the requested health service/treatment of Consumer Directed Person Assistance; 1 Client- 168 hours/week is medically necessary.