Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, diabetes mellitus type 2, diabetic neuropathy, congestive heart failure, chronic obstructive disease, coronary artery disease, hepatitis C, and lower back pain.

Treatment: Consumer directed personal assistance program (CDPAP) 12 hours per day-7 days per week for a total of 84 hours per week.

The insurer denied coverage for CDPAP 12 hours per day-7 days per week for a total of 84 hours per week.

The denial is overturned.

This patient has extensive medical history associated with functional impairment and needs assistance with most daily activities. She lives with her daughter. The patient receives personal care services, provided through CDPAP 5.5 hours per day, 7 days per week, total of 38.5 hours per week. A family friend is the CDPAP aide. The patient's daughter provides some assistance during non-CDPAP hours. The daughter (as patient designee) requested increase of CDPAP services to 84 hours per week, which was denied. An external appeal was requested.

Functional decline in the elderly is generally due to the combined effects of various medical conditions resulting in physical and/or cognitive impairment. Other factors include social and economic circumstances (e.g., caregiver support). The patient has multiple medical conditions that are probable contributing factors to her functional impairment.

Performing daily activities with pain, dyspnea, and fatigue (and specifically for this patient all symptoms are reported as severe) is physically stressful and can lead to anxiety and depression [Uniform Assessment System (UAS reports patient feels sad/depressed due to her health]. Caregiver assistance with daily tasks can help relieve some of the burden associated with routine daily life.

Managed Long-Term Care (MLTC) policy 16.07 states that managed long term care plans must assure that the plan of care can meet any of the patient's unscheduled or recurring daytime or nighttime needs for assistance. Therefore, the patient's need for assistance with transfers, walking, toileting, meals that occurs at various unscheduled and/or recurring times during the day must be considered in the determination of the patient's personal care service hours. Additional hours would not be for safety monitoring and supervision. The patient needs assistance at various times throughout the day for safe and proper completion of activities of daily living (ADLs).

Considering the patient's medical history and functional status as noted in the available records, it is apparent that the patient needs a significant level of assistance for most ADLs and instrumental activities of daily living (IADLs). Therefore, it is medically necessary, and in the patient's best interest, to have a caregiver present throughout the day to assist with daily activities. The patient needs assistance for routine housekeeping tasks; preparation and setup of meals (and possibly assist at times with eating as needed); routine morning and evening ADLs (e.g., bathing, dressing, personal hygiene); unscheduled/recurring activities that occur throughout the day, including toileting/incontinence care, and mobility (transfers, walking). Without adequate assistance, the patient is at risk for adverse health and safety events, e.g., skin damage due to incontinence; urinary tract infections (UTI), falls/injury, decreased food/fluid intake. Assistance from a caregiver can help with proper and timely completion of daily activities and help relieve some of the physical stress experienced by the patient when performing daily tasks.

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

The insurer's denial of coverage for CDPAP 12 hours per day-7 days per week for a total of 84 hours per week is overturned. Medical Necessity is substantiated.