Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident. 
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Services: 8 Hours per Day - 7 Days per Week - Total of 56 Hours. 

The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: 8 Hours per Day - 7 Days per Week - Total of 56 Hours. 
The determination is overturned. 

This is a male patient with a past medical history of a cerebrovascular accident (CVA) with right hemiplegia, diabetes mellitus type 2, bladder incontinence, coronary artery disease, benign prostatic hyperplasia (BPH), hypertension, gastroesophageal reflux disease (GERD), osteoarthritis, and hyperlipidemia who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 4 hours/day, 5 days/week, to total 20 hours/week based on a video assessment.  

There was a request to increase CDPAP services and the patient underwent an assessment video. The patient's medical provider sent a letter stating the patient was wheelchair-bound from a remote stroke with right hemiparesis, had insulin-dependent diabetes mellitus, relied on his family for home care and was requesting the maximum number of reimbursed hours per care as the patient was dependent on family for all Activities of Daily Living (ADLs).
The insurer provided a final adverse determination denial notice continuing to deny the request to increase CDPAP services stating the universal assessment showed that most of the patient's activities of daily living were the same when compared to a prior universal assessment.  The patient's primary care physician (or provider) (PCP) provided another letter stating they were not sure of the criteria that was used for CDPAP services, but the patient had right-sided hemiplegia from a previous stroke, was on 13 medications, including insulin, required assistance to prepare food and serve it, bathe, and even go to the bathroom. At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP) Services: 8 Hours per Day - 7 Days per Week - Total of 56 Hours per Week. 

The services are medically necessary. 

There is documentation from the patient's medical provider of the medical necessity of increased CDPAP services. There is documentation from the plan's own assessment of a decline in ADL status and a deterioration of overall self-sufficiency when compared to the previous assessment. In addition, the most recent assessment stated the patient required at least limited assistance with walking, locomotion, transfer toilet, and toilet use and he therefore had unpredictable and unscheduled care needs that spanned a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. Because the patient has 24-hour care needs a time-based assessment tool should not have been utilized. The patient requires assistance outside of the hours he does not have informal support. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies.