Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Soft Palate Carcinoma, Percutaneous Endoscopic Gastrostomy
Treatment: Consumer Directed Personal Assistance Program (CDPAS)
services; 12 hours per day, 7 days per week - for a total amount of 84 hours per week.
The insurer denied the Consumer Directed Personal Assistance Program (CDPAS)
services; 12 hours per day, 7 days per week - for a total amount of 84 hours per week.
The denial was overturned.

This is a female patient was diagnosed with carcinoma of soft palate in late 2019, status post palatectomy, percutaneous endoscopic gastrostomy (PEG) placement for nutrition and medications. She has a history of hypertension, hyperlipidemia, peripheral vascular disease, urinary incontinence, osteoarthritis, vitamin deficiency. She was scheduled to start chemotherapy in early 2020 (not known if she is still receiving treatment). The patient has severe functional impairment. The patient receives home care services through Consumer Directed Personal Assistance Program (CDPAP). She lives at home with her goddaughter who is the CDPAP aide. The aide provides assistance with all IADLS and ADLs plus management of the patient's PEG (daily local care, administers feedings, medications) and vital signs. The patient had been approved for CDPAP 70 hours per week. She requested increase to CDPAP 84 hours per week due to the need for additional time for shopping and housework related to COVID-19.

The patient has a few medical conditions that contribute to her functional decline. The most recent diagnosis was carcinoma of the palate, treated with surgery and chemotherapy. In recent months, it is likely that this has been the primary cause of her increased weakness and fatigue (decline of ADL status and self-sufficiency from previous assessment was noted). The patient has other chronic problems, including osteoarthritis and peripheral vascular disease. The nursing comments in the UAS describe weakness in upper and lower extremities; joint stiffness with decreased ROM; pain in back, joints, lower extremities. The patient also has frequent dizziness, and reports fatigue to the extent that she is unable to finish normal daily activities. The patient's nutritional status is at risk, with low body weight (BMI category: underweight). Malnutrition is a frequent consequence of cancer, and can adversely affect
prognosis. These problems all contribute to the patient's functional impairment. It is apparent the patient cannot move around her home or perform any ADLs without substantial assistance. 

The patient's health has been severely compromised in recent months due to cancer and the stress of surgery and chemotherapy. This has been further complicated by her chronic medical conditions (arthritis, PVD) which increase the burden of all daily tasks as a result of pain and limited mobility of her extremities. It is necessary that she avoids any additional problems such as skin injury (due to incontinence and/or pressure ulcers), falls/injuries, and further nutritional impairment. This requires assistance with ADLs from the aide at various times throughout the day and night. The aide leaves the home for shopping and errands; and this may be more time consuming recently; but when she is home with the patient, there is no time limit for when she needs to provide care.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.
The carrier's denial of coverage for Consumer Directed Personal Assistance Program (CDPAS) services; 12 hours per day, 7 days per week - for a total amount of 84 hours per week is overturned. The medical necessity is substantiated.