Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive decline, General debilitation. 
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split-shift) - a total of 168 hours per week. 

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split-shift) - a total of 168 hours per week. 

The denial is overturned. 

This is an elderly male with progressive worsening of physical condition. As per medical records provided and his daughter, the patient requires assistance with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) due to malignant neoplasm of colon, nephrostomy status and Coronary Artery Disease (CAD).  He also has depression, anxiety, pain, dizziness, unsteady gait, difficulties walking, diarrhea and nausea with vomiting. 

The patient's memory and cognition functions have declined since chemotherapy treatments. His sister reports overall self-sufficiency and management of Activities of Daily Living (ADLs) status has declined since recent hospitalizations. He has declining of strength in his legs and increased muscle weakness with resultant poor physical conditioning. He is not participating in any meal preparation or shopping, and he is completely dependent on shopping and meal preparation by caregivers. The patient is also completely dependent the caregiver for all housework. Family has been setting up medications and medication reminders. 

The patient has not used stairs recently. He requires weight bearing assistance for bathing, personal hygiene and dressing, including pulling up and fastening pants. He requires assistance with washing his face, combing hair and oral hygiene. 

Recent hospitalization for sepsis has led to decreased mobility and ambulatory stability. He requires significant weight bearing assistance from caregiver with walking and locomotion and is only able to walk a few steps using a walker. He has poor balance and coordination and weakness in both legs and requires significant weight bearing assistance from caregiver to transfer to toilet. 

There are several factors which are important to note. This person requires nephrosotomy care with documented ongoing complications. There were 3 reported admissions to hospital within 90 days. There is evidence of ongoing confusion which would limit activities of self-care. There are reports of inability to bear weight without assistance. 

The gradual decline is well documented with significant loss of cognitive and physical abilities. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split-shift) - a total of 168 hours per week is substantiated.