Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-small cell lung cancer with brain metastases
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 5.5 hours per week - 7 days per week - for a total of 38.5 hours per week
The insurer denied Consumer Directed Personal Assistance Program (CDPAP): 5.5 hours per week - 7 days per week - for a total of 38.5 hours per week.
The determination is overturned.

This is a female patient with a past medical history of non-small cell lung cancer with brain metastases, peripheral vision loss of left eye, anxiety, depression, chronic obstructive pulmonary disease (COPD), anemia, gastroesophageal reflux disease (GERD), and migraines who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 24.5 hours/week based on an assessment. One of the patient's medical providers sent a letter documenting the patient's chronic medical condition and intensive treatment of non-small cell cancer with brain metastases which had resulted in extreme weakness and fatigue impacting the patient's ability to independently complete activities of daily living (ADLs). 
The patient underwent a video assessment assessing the patient at total assistance with the task of ordinary housework while maximum assistance with tasks of meal preparation, managing medication, and shopping. With the tasks of managing finances, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility the patient was assessed at extensive assistance while limited assistance with task of phone use. The patient was assessed at independent with the task of eating. The assessment also noted the patient had a fall with injury. The tasking tool estimated 38.5 hours/week.

The patient's neuro oncologist provided a letter noting the patient required the use of a cane for safety and support while ambulating and this was a recent change from a previous visit. The provider also noted the patient was completely dependent on a caregiver, was at risk for falls, could become disoriented, and the current amount of home care hours were not sufficient and the provider recommended an increase in home care hours by 2 hours/day. The patient's husband provided an appeal letter  noting the patient's deterioration of health and the need for constant assistance with daily activities. The husband noted his daughters recently moved away and he no longer had them as backup for informal support. He noted the patient would be alone at times when he was at work and he was concerned about her ability to evacuate the home and emergency, call for help, or use the stairs.  At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP): 5.5 hours per week - 7 days per week - for a total of 38.5 hours per week.
The services are medically necessary.
There is documentation from the patient's medical providers of medical necessity of increased CDPAP services. The patient's husband documented a loss of informal support and his need to work at his own job leaving the patient alone. It cannot be assumed that the patient has informal support outside of all of the currently assigned CDPAP service hours. The plan's assessment tasking tool estimated assistance needs at 38.5 hours/week. The plan's assessment documented a decline in ADL status and a deterioration of overall self-sufficiency in the preceding 90 days. The patient requires extensive assistance with the tasks of walking, locomotion, transfer toilet, and toilet use and therefore, has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs when the patient does not have informal support.