Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary heart disease, cataracts, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, osteoarthritis, and spinal stenosis

Treatment: Consumer-directed personal assistance services (CDPAS) 56 hours per week

The insurer denied coverage for consumer-directed personal assistance services (CDPAS) 56 hours per week.

The denial is upheld.
 

This is an elderly patient with chronic medical problems including hypertension, headaches, and osteoporosis.  The patient lives with her spouse in a 4-bedroom home.  Her daughter and son-in-law live on the 2nd floor of the house.  The insurer decreased her previously approved CDPAS (consumer-directed personal assistance services) 7 days per week, 8 hours per day; 56 hours per week to Shared Mutual CDPAS 7 days per week, 8 hours per day; 56 hours per week.  The patient is requesting reinstatement of the (individual) CDPAS 56 hours/week.  

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive skills are described as "Modified independent."   She is "self-directing, able to make daily decisions, and consult with family when making complex decisions."  In addition, "Member verbalized will call 911/activate PERS and family in event of an emergency."  The patient reportedly requires extensive to maximal assistance for completing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping.  The patient reportedly requires extensive assistance for bathing and lower body dressing.  Limited assistance is reportedly needed for upper body dressing and toilet transfer/use.  The patient is otherwise independent for personal hygiene, eating, bed mobility, locomotion and ambulation (uses a cane or walker).  She is reportedly frequently incontinent of bladder and continent of bowel.  There has been no change in her activities of daily living (ADL) status, self-sufficiency over the prior 90 days.   The patient's condition and functional deficits are not at a level or unpredictable as to require the requested CDPAS (consumer-directed personal assistance services) 56 hours/week.

This physician would agree that the patient may benefit from monitoring for safety; particularly due to her decreased mobility and falls risk.  However, CDPAS for companion care or safety supervision without the direct provision of ADL task assistance is not a covered service.  The patient also has family (daughter and son-in-law) who live in the same house on the second floor.  They are involved, attentive and available to assist their parents in the event of an emergency.  Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the mutual CDPAS 8 hours/day, 7 days/week, for a total of 56 hours/week.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations.  All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, the requested coverage for consumer-directed personal assistance services (CDPAS) 56 hours per week is not medically necessary.   

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for consumer-directed personal assistance services (CDPAS) 56 hours per week services is not substantiated.  Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the mutual CDPAS 8 hours/day, 7 days/week, for a total of 56 hours/week.