Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, difficulty walking
Treatment: increase in consumer directed personal assistance services (CDPAS), from 36 hours per week to 84 hours per week.
The insurer denied increase in consumer directed personal assistance services (CDPAS), from 36 hours per week to 84 hours per week.
The determination is overturned.


The patient has a past medical history of hypertension, diabetes mellitus type 2, dementia, urinary incontinence, hyperlipidemia, obesity, osteoarthritis, breast cancer, peripheral neuropathy, and psoriasis who had been assigned Consumer Directed Personal Assistance Program CDPAP services 36 hours/week based on an assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with managing finances, stairs, transportation, bathing, and dressing lower body. With the tasks of managing medication, phone use, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and eating the patient was assessed at limited assistance while independent with task of bed mobility.

The patient was treated with insulin for her diabetes mellitus with endocrinology notes stating the patient was using both NovoLog insulin and Basaglar requiring short acting insulin 3 times per day. The patient was seen by her neurologist noting progressive cognitive decline, with family noting there was a problem with her glucoses being out of control and the patient was forgetting to take her afternoon insulin. This office note stated a diagnosis of Alzheimer's dementia recommending greater supervision in terms of medication administration, especially her insulin. A magnetic resonance imaging (MRI) scan of the brain was ordered. The patient was seen again in the office by neurology with the office notes stating MRI showed significant bitemporal atrophy and an electroencephalogram (EEG) was without epileptiform activity. In addition, office notes stated the patient needed increased home health aide supervision at least 12 hours/day. The patient was started on Aricept. The patient underwent another assessment tool assessing the patient at maximum assistance with the tasks of meal preparation, ordinary housework, and shopping while extensive assistance with the tasks of managing finances, stairs, transportation, bathing, and dressing lower body. With the tasks of managing medication, phone use, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and eating the patient was assessed at limited assistance while independent with the task of bed mobility.

Notes from the assessment stated the patient lived alone and had a Mini-Mental State Examination (MMSE) of 29 out of 30. The insurer sent an initial adverse determination denial notice denying request to increase CDPAP services stating it was not medically necessary. The insurer sent a final adverse determination denial notice denying request to increase CDPAP services stating there were no unmet needs identified and the patient should continue to follow-up with her medical providers to ensure the receipt of proper individual treatment and determine effectiveness of her medication regimen which could prevent further deterioration of the patient's health status. The denial letter also noted the medical equipment the patient had in her home. Lastly, the denial letter stated the plan was not required to include safety monitoring as a separate task on their task based forms or calculate any minutes allotted for safety monitoring as part of the total personal care service hours.

The patient's nephew provided a letter which stated in the last 6 months the patient had difficulty maintaining stable blood sugar levels due to her dementia, at times forget to eat, forgetting her injection, or doubling her dose of injection. The nephew noted if someone was there from 9 AM to 9 PM all of the patient's meals could be prepared and insulin injections for all meals could be administered. The patient's CDPAP aides both provided letters noting the decline in the patient's memory and health and the patient had forgotten if she had administered her insulin on multiple occasions and had doubled the dose. The patient was seen by the primary care physician (PCP) with office notes stating the patient had been taking insulin incorrectly and patient's dementia has gotten worse. On this same date, the PCP filled out Department of Health (DOH)-4359 form which stated the patient had progressive dementia, and needed assistance with medication administration, transportation to multiple specialists, and a recent abnormal MRI requiring further follow-up as there was suspicion for malignancy. The DOH form also stated there was medical risk for the patient not to have the maximum number of home care hours. The patient's healthcare advocate requested an expedited external appeal on behalf of the patient. The healthcare advocate letter stated that the patient had spikes in glucose and could not remember if she had eaten or had drinks which has led to hypoglycemia.

At issue is the medical necessity of an increase in consumer directed personal assistance services (CDPAS), from 36 hours per week to 84 hours per week.

The requested services are medically necessary.

There is documentation from the patient's endocrinologist, neurologist, and PCP of a decline in physical and cognitive function, even more so since the last assessment. The patient was also now being seen by hematology/oncology for an abnormal brain MRI. Due to the patient's dementia she has underdosed and overdosed on insulin causing hyperglycemia and hypoglycemia. The patient requires at least limited assistance with walking, locomotion, transfer toilet, and toilet use. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. If the patient had twelve hours/day of CDPAP services the patient would have assistance receiving appropriate doses of insulin and ensuring adequate oral intake. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and instrumental activities of daily living (IADLs). 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 84 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.