Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tuberculosis. 
Treatment: Consumer directed personal care assistance services, 4 hours/day, 5 days/week, a total of 20 hours/week. 

The insurer denied consumer directed personal care assistance services, 4 hours/day, 5 days/week, a total of 20 hours/week. 
The determination is overturned. 

This is a female patient with a past medical history of hypertension, osteoarthritis, migraines, latent tuberculosis (TB), and memory loss who requested Consumer Directed Personal Assistance Program (CDPAP) services and underwent a video assessment assessing the patient at total assistance with managing finances while limited assistance with tasks of meal preparation, ordinary housework, shopping, and dressing lower body. The patient was assessed at extensive assistance with task of transportation while supervision with task of managing medication. The patient was assessed as independent with tasks of phone use, stairs, bathing, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. Notes from the assessment stated it was the patient's first assessment and the patient needed help with cooking, dressing lower extremity, shopping, et cetera ("and the rest"). In addition, the note stated the patient lived with her daughter and needed reminders for medications. The tasking tool estimated 3.85 hours/week. The patient was assigned 4 hours/week. The insurer sent a final adverse determination denial notice denying request to increase CDPAP services to 4 hours/day, 5 days/week, to total 20 hours/week stating it was not medically necessary. The denial stated the patient's provider had recently diagnosed the patient with tuberculosis and the patient had joint pain and was unable to use the bathroom or climb stairs independently and current hours were not enough to meet the patient's needs. The denial stated based on the clinical review the patient's personal care tasks should be able to be done in the time that had been provided during the current hours and the clinical information did not support a need for additional personal care hours. The patient's primary care physician (or provider) (PCP) provided a letter stating the patient's medical diagnoses and that the patient needed more than 4 hours of help from her daughter for day-to-day activities, mobility, and medications. At issue is the medical necessity of consumer directed personal care assistance services, 4 hours/day, 5 days/week, a total of 20 hours/week. 

The services are medically necessary. There is documentation from the patient's medical provider of medical necessity of increased CDPAP services. The universal assessment via video underestimated the patient's care needs. Despite the PCP and the patient's assessment stating she needed help with medication reminders and assistance, stairs, and transfer toilet, no hours were provided on the tasking tool to account for these assistance needs. 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 4 hours/day, 5 days/week, a total of 20 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.