Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbago, lumbar radiculopathy, lumbar disc degenerative disease, left ankle pain, arthritis, fibromyalgia, chronic pain insomnia, and urinary incontinence
Treatment: Increase in Consumer Directed Personal Assistance Program (CDPAP) Service for a total of 70 hours per week
The insurer denied the increase in Consumer Directed Personal Assistance Program (CDPAP) service for a total of 70 hours per week.
The denial is overturned. 

The patient is a female with multiple conditions, including lumbago, lumbar radiculopathy, lumbar disc degenerative disease, left ankle pain, arthritis affecting several joints, fibromyalgia, chronic pain, insomnia and urinary incontinence. The patient is homebound and lives with her three children, who act as her CDPAP (Consumer Directed Personal Assistance Program) representative and aides. She is appealing the denial of increase in CDPAP from 49 to 70 hours per week.

The patient's most recent assessment shows minimally impaired cognition and functional status, total dependence with meal preparation, housework, managing finances, and shopping, maximal assistance with managing medications, transportation, bathing, lower body dressing, walking, locomotion, toileting, and eating, and extensive assistance with phone use, personal hygiene, bed mobility, and upper body dressing. She has limitations due to joint stiffness, pain, limited ROM (range of motion), and weakness. Compared to a previous assessment, there is a decline in shopping, toilet use, and eating.

An appeal letter states that the patient's ability to perform ADLs (activities of daily living) has declined and the patient needs additional hours for care after the aide's seven-hour shift ends. Logs were provided, showing times of assistance needed with toileting, transferring, and walking. The patient's doctor's letter is appealing based on the need for maximal assistance with ADLs and need for aide to assist with ambulation, toileting and transfer/repositioning at unscheduled times through the day and night.

Yes, the increase in CDPAP service for a total of 70 hours per week is medically necessary.

Medically necessary services are those which are:
1) safe 2) effective 3) generally accepted national standard of medical practice 
not provided primarily for convenience of the patient or the practitioner 4) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice.

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with ADLs, health maintenance activities, and routine support services. This patient is homebound. She has chronic pain, limited mobility, requires assistance with weight bearing, and she is incontinent of bladder. This patient requires assistance with all ADLs and personal care needs. The most recent assessment showed deterioration in functional status compared to the previous assessment. Information provided shows that the patient's condition continues to deteriorate since the most recent assessment. She has more urinary incontinence and requires more assistance with shopping, toilet use, and eating compared to the previous assessment. Logs provided show the patient requires assistance with toileting, transferring, and walking beyond the currently approved seven hours per day. Based on the progression of this patient's condition, the proposed increase in CDPAP to total 70 per week is medically necessary to meet this patient's needs for assistance, as noted above.