Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary heart disease, diabetes mellitus, hyperlipidemia and osteoarthritis. 
Treatment: Consumer directed personal assistance services (CDPAS) of 6 hours per day, 7 days per week for a total of 42 hours per week. 

The insurer denied coverage for consumer directed personal assistance services (CDPAS) of 6 hours per day, 7 days per week for a total of 42 hours per week. 

The denial is overturned. 

This elderly female has an extensive medical history and functional impairment which limits her ability to perform daily activities. The Uniform Assessment System (UAS) indicates patient lives with her son and daughter-in-law. She receives assistance with activities of daily living (ADL) and instrumental ADLs through Consumer Directed Personal Assistance Services (CDPAS); it is noted that her daughter-in-law is the CDPAS aide. The patient receives CDPAS 30 hours per week. The UAS indicates services are 6 hours per day, 5 days per week. The external appeal, section 15, includes comments stating that the patient cannot walk or stand on her own; the patient is the only one at home on weekends and the family is concerned that she may fall, and no one knows until Monday. UAS reports son works Monday-Saturday irregular hours. However, the daughter-in-law is the CDPAS aide; and so it is not clear why the patient is alone on weekends. The son requested CDPAS 6 hours per day, 7 days per week, which was denied. The insurer's final adverse determination letter includes comments stating that the daughter-in-law is traveling to China and will not be available to assist during non-service hours (no other information is provided about family members traveling). An external appeal was requested for CDPAS 42 hours per week. 

The patient needs extensive assistance with all aspects of toileting, i.e., toilet transfer, toilet use, incontinence care. Providing extensive (weight-bearing) assistance with toileting can be time and labor intensive for the caregiver (in this case, patient also needs extensive assistance to walk to the toilet). The cause of the patient's incontinence is not identified, but for people with impaired mobility, delay in reaching a toilet is a common cause of functional incontinence (i.e., inability to reach a toilet in time). Review of the tasking tool (UAS-ATSP Summary of Hours Recommended) raises questions regarding toileting. For each toileting task (toilet use, transfer, incontinence), frequency is noted as 6 per day and 42 per week. No time is allocated for toilet use (minutes per week "0"; reason not noted); and only 3 episodes of care per day are noted for incontinence care and transfer toilet. It is not clear how the patient manages toileting and incontinence care when alone (external appeal comments indicates patient is alone on weekends). If she is not cleaning herself properly and not changing pullup when it is wet, she is at risk for skin damage due to prolonged exposure to moisture and poor cleaning/hygiene. 

The records provided for review support medical necessity for caregiver assistance with the patient's daily activities. The patient needs assistance with all ADLs and several IADLs every day of the week. Therefore, CDPAS hours need to be extended to 7 days per week. CDPAS 6 hours per day has been needed to support the patient's care needs for 5 days per week and should be extended to 7 days per week.  The time estimated by the tasking tool needs to reflect the actual time needed for all the patient's daily care needs. Re-evaluation will determine whether CDPAS 6 hours per day adequately meets the patient's daily ADL and IADL care needs. 

Consumer Directed Personal Assistance Services 6 hours per day, 7 days per week, total of 42 hours per week is medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance Services (CDPAS) of 6 hours per day, 7 days per week for a total of 42 hours per week is overturned. Medical Necessity is substantiated.