Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Legal blindness
Treatment: Personal Care Aide (40 Hours/week; Consumer Directed; 1 client)
The insurer denied Personal Care Aide (40 Hours/week; Consumer Directed; 1 client).
The determination is overturned.

The patient is a female with a past medical history of legal blindness and history of meningioma who requested Consumer Directed Personal Assistance Program (CDPAP) services and underwent a video assessment.  Notes from the assessment stated the patient's son set up her medications and handed it to her and the patient administered the medication independently. The patient was observed to be walking with a slow and steady gait while holding onto her surroundings and being supervised by her son. 
The patient's ophthalmologist provided a letter stating the patient was legally blind in both eyes with no potential for visual improvement due to multiple eye conditions. The provider noted that due to the patient's lack of functional vision the patient required assistance for all activities. The patient's primary care physician (or provider) (PCP) provided a letter in support of 8 hours of home care services 7 days/week. The provider noted the patient was not able to cook, do laundry, or other household chores safely. The provider noted the patient had multiple falls and household accidents due to her poor vision. The insurer sent a final adverse determination denial notice denying request to increase CDPAP services on partially approving services 14 hours/week. The denial stated the patient was able to dial 911 in an emergency, was able to walk without using an assistive device and needing only someone to watch over her, was able to direct her own care and make needs known, was able to wash her face, brush her teeth, and use the toilet without help, was able to bathe, dress upper and lower body, and eat without help, and lived with a family member who was willing to assist with the patient's needs. The denial also stated they had received a letter from the patient's doctor and the doctor must not recommend the number of our services that the patient should be approved to receive.  At issue is the medical necessity of Personal Care Aide (40 Hours/week; Consumer Directed; 1 client). 
The services are medically necessary. There is documentation of medical necessity of increased CDPAP services by the patient's medical provider. There is documentation that the patient requires at least supervision with walking and locomotion which are unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The plan made the assumption that the patient's children could provide informal help outside of their recommended CDPAP service hours of 14 hours/week. 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 (ADLs) and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 40 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.