Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: consumer directed personal assistance (CDPAS) a total of 91 hours per week 
The insurer denied (CDPAS) a total of 91 hours per week.
The determination is upheld.


The patient has a past medical history of glaucoma, osteoporosis, hypertension, hyperlipidemia, diabetes mellitus, peripheral vascular disease, anemia, and osteoarthritis who had been assigned consumer directed personal assistance (CDPAS) services 4 hours/day, 5 days/week to total 20 hours/week based on an assessment tool performed  assessing the patient and maximum assistance with ordinary housework and managing finances while extensive assistance with meal preparation, stairs, shopping, and transportation. The patient was assessed at limited assistance with bathing, personal hygiene, dressing upper/lower body, and toilet use while supervision with walking, locomotion, and transfer toilet. With tasks of managing medication and phone use the patient was assessed at set up only and independent with tasks of bed mobility and eating. The patient had been seen for a medical visit noting her past medical history as above. The patient saw her primary care physician (or provider) (PCP) again via telemedicine noting the patient needed a video visit to assess need for more home health aide hours. Since the patient's husband passed earlier in the month the daughter has been her home health aide 4 hours/day 5 days/week and her daughter works outside of the home. The patient did not feel safe being alone in her home. The office visit also noted the patient walked with a cane or walker and required assistance with most activities of daily living (ADLs) and was dependent on her daughter for Instrumental activities of daily living (IADLs). The office visit note stated that provider would complete forms with request for more home care hours.
The patient underwent a telephonic assessment tool assessing the patient at extensive assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, transportation, and bathing while limited assistance with tasks of personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. With the tasks of phone use and eating the patient was assessed as independent. The insurer approved temporary individual CDPAS to total 91 hours/week. The insurer sent an appeal decision stating the appeal was denied noting the plan approval changed from 91 hours/week to 21 hours/week of CDPAS. This appeal denial stated the patient was previously receiving shared CDPAS services, 70 of which were attributed to the patient's spouse and 21 which were attributed to the patient to total 91 hours/week. Lastly, the appeal denial stated 21 hours/week of CDPAS care was sufficient to support her current care needs. The patient's primary care physician provided a letter stating the patient's chronic medical problems and also stating the patient needed more hours of home care to remain safely in the home. An appeal form filled out by the patient's provider stated the patient needs a minimum of 8 hours/day, 7 days/week due to her medical conditions and needs help with ADLs. At issue is the medical necessity of consumer directed personal assistance services (CDPAS) a total of 91 hours per week. 

The services are not medically necessary. The patient previously had shared services with her husband to total 91 hours/week. The patient was attributed hours for 21 hours/week. Although she did have a decline in managing medication, walking, locomotion, transfer toilet, and bed mobility this change in status would not represent an additional 70 hours/week. Her medical provider requested 8 to 9 hours/day of CDPAS services. 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 91 hours/week are not medically necessary for this patient.