Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colon Cancer, Heart Disease
Treatment: Consumer directed personal assistance program (CDPAP) 8 hours/day (hours per day) - 4days/week- for a total of 32 hours/week
The insurer denied coverage for:  Consumer directed personal assistance program (CDPAP) 8 hours/day- 4days/week- for a total of 32 hours/week
The denial is: Upheld  
This is adult with colon cancer and heart disease. The patient lives alone in a 1-bedroom apartment. The plan approved consumer directed personal assistance program (CDPAP) 6 hours/day - 4 days/week - for a total of 24 hours/week and the request is for 8 hours/day- 4 days/week- for a total of 32 hours/week, leading to an external review.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is described as modified independent. The patient is reportedly total dependent to maximal assistance for performing much of the Instrumental Activities of Daily Living (IADL) tasks including shopping, ordinary housework and meal preparation. Extensive assistance is reportedly needed for bathing and lower body dressing. Limited assistance is reportedly needed for personal hygiene, upper body dressing, eating, bed mobility, locomotion, toilet transfer/use and ambulation. The patient reports being occasionally incontinent of bladder and continent of bowel. There have been no reported falls over the prior 90 days.  

The patient's cognitive status and functional ability are much the same when compared to the UAS report. The letter from the patient's treating physician discussing the patient's underlying clinical condition and associated functional impairments was also reviewed. The patient's condition, cognitive status and functional needs are not at a level or unpredictable as to require the requested CDPAP 32 hours/week. The patient may benefit from additional monitoring. However, safety monitoring under CDPAP does not include monitoring an individual (For example (e.g.), falls risk, companion care) when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained at this time by the approved CDPAP 6 hours/day - 4 days/week - for a total of 24 hours.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested CDPAP 8 hours/day- 4 days/week- for a total of 32 hours/week is not medically necessary.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for consumer directed personal assistance program (CDPAP): 8 hours per day - 4 days per week - for a total of 32 hours per week is not substantiated.