Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular Accident 

Treatment: Increase of Consumer Directed Personal Assistance Program (CDPAP) Personal care Services (PCS) - Housekeeping / Personal Attendant - Level one and Level two, 4 hours per day, 7 days per week

The insurer denied coverage for increase of Consumer Directed Personal Assistance Program (CDPAP) Personal care Services (PCS) - Housekeeping / Personal Attendant - Level one and Level two, 4 hours per day, 7 days per week

The denial is overturned

This case is regarding the denial of coverage for increase of consumer directed personal assistance program (CDPAP) Personal care Services (PCS) - Housekeeping / Personal Attendant - Level one and Level two, 4 hours per day, 7 days per week.  The most recent assessment conducted was conducted via telehealth.  The report states that the patient lives alone with family close by.  The patient has had multiple diagnoses to include constipation, essential (primary) hypertension, gastroesophageal reflux disease (GERD) without esophagitis, major depressive disorder, other seasonal allergic rhinitis, pure hypercholesterolemia, unspecified abnormalities of gait and mobility, and unspecified urinary incontinence.  The patient was alert and oriented to person, place, time, and history.  The patient had no psychotic features indicated.  The patient continued to have weakness in the bilateral upper and lower extremities and continued with incontinence of the bladder for which they use diapers/briefs. The patient remained independent for changing their adult garments and used a cane for ambulation.  The patient had visited the emergency department in the last 30 days for severely elevated blood pressure at 200 systolic over 100 diastolic.  The patient otherwise had no hospitalizations in the past 30 days.  The patient endorsed pain that was not controlled, and continued to need limited assistance when taking medications.  The patient endorsed arthritic pain to the back, upper and lower extremities, and is frequently tired and fatigued with the inability to perform day-to-day tasks.  The report anticipated the patient had carpal tunnel surgery to both hands.  The report stated the patient was receiving level 1 (housekeeping services) 4 hours a week, level 2 (personal attendant) for 17 hours at 3 hours/day / 7 days/week for a total of 21 hours/week.  

Personal assistant services (PAS) allow patients to remain in the comfort of their own home to receive care/treatment rather than residing in a skilled nursing facility, long-term acute care, or assisted living.  The documentation provided for the review noted that the patient was previously receiving 21 hours/week of personal care services given their functional impairments associated with their physical condition.  A prior assessment conducted indicated that 21 hours/week of personal care services would meet the needs of the patient with no significant changes in their overall functionality at that time.  However, following the recent admission to the hospital, it was determined that a slight increase in personal care services hours would be reasonable to address the safety of the patient.  The additional increase in hours is appropriate until the next reassessment, which should occur within 6 weeks of the review.  At that time, a determination can be made if the patient needs to continue with the increased hours or if personal care services hours can be reduced to 21 hours/week.  At this time, the prior determination is overturned.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for increase of Consumer Directed Personal Assistance Program (CDPAP) Personal care Services (PCS) - Housekeeping / Personal Attendant - Level one and Level two, 4 hours per day, 7 days per week is substantiated.