Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis with Associated Decline in Mobility
Treatment: CDPAP (Consumer Directed Personal Assistance Program); 12 hours per day- 7 days per week- a total of 84 hours per week
The health plan denied CDPAP; 12 hours per day- 7 days per week- a total of 84 hours per week.
The determination is overturned.


The patient has type 2 diabetes, diabetic neuropathy, morbid obesity, chronic pain due osteoarthritis with associated decline in mobility, antiphosophlipid syndrome, chronic deep vein thrombosis (DVT), and seizures. Her health care plan approved 6 hours per day - 7 days per week (42 hours per week) of CDPAP services. The patient's healthcare provider subsequently requested an increase to 84 hours per week (12 hours per day 7 days per week) of CDPAP services and this decision was denied by the health plan.
A letter of support for this request was provided by the patient's psychiatrist. This letter states that she needs more hours of Home Health Aid (HHA) assistance due to suffering from worsening depressive symptoms as part of her major depressive disorder and generalized anxiety disorder. They state she had a recent emergency room (ER) visit secondary to stress at home.
The most recent office visit note from the primary care physician was provided as well. It states only that the patient will benefit greatly from bariatric surgery, presumably due to the contribution of obesity complicating her other medical conditions. A letter of support from a paralegal was provided which outlines the medical and legal necessity for the increased hours for the patient. This letter posits that the patient's assessment underestimates the time required for assistance for the patient, especially due to unpredictable and unscheduled needs such as toileting. This letter includes a recommendation from the treating physician: "She also requires substantial assistance with toileting and post-elimination hygiene, transferring, and ambulating...While she can make her needs known, she requires assistance with changing her diaper as soon as possible to prevent skin breakdown and infections."
The health plan reports that the additional hours were denied for several reasons; principal among them is that the task assessment determined that her needs can be met in 42 hours per week, and additional hours would be for safety monitoring and supervision (which is not covered under the plan).
A Uniform Assessment System (UAS) was performed. She was noted to require maximal assistance for meal preparation, managing finances, managing medications, and shopping. She requires total dependence for ordinary housework. She requires maximal assistance for bathing and dressing the lower body. Toilet use requires maximal assistance. Walking, locomotion, dressing upper body and toilet transfer require extensive assistance. She has frequent urinary incontinence (at least daily) and is continent of stool.
At issue is the medical necessity of CDPAP; 12 hours per day- 7 days per week- a total of 84 hours per week.

The requested health service/treatment of CDPAP; 12 hours per day- 7 days per week- a total of 84 hours per week is medically necessary for this patient. The Uniform Assessment System (UAS) and associated task hours tool outlines a minimum required set of hours for the tasks which must be completed for the patient to attend to her health needs. However, this tool does not accurately reflect the reality of a patient with ongoing and unscheduled health needs. Because the patient needs assistance with ambulation, toileting, toilet transfer, and locomotion, it is not reasonable to believe that these tasks can be completed within a six hour window each day. An additional major concern is around toileting. Because the patient has incontinence and relies on caregivers for changing diapers, she would require prompt attention for any unscheduled toileting needs. The patient's treating physician is correct that without tending to these needs the patient would suffer from skin breakdown and associated sequelae, including but not limited to increased risk for fungal and urinary tract infections. The use of durable medical equipment to assist with this patient's health needs supplements but does not substitute the requirement for human assistance with her activities of daily living (ADLs) and instrumental activities of daily living (IADLs).