Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia.
Treatment: Personal Care Services (PCS) Level II Weekend/Holiday, Consumer Directed Personal Assistance (CDPA) Basic -15 Minutes.
The insurer denied: Personal Care Services (PCS) Level II Weekend/Holiday, Consumer Directed Personal Assistance (CDPA) Basic -15 Minutes.
The health plan's determination is: Overturned.

The patient is a female with a past medical history of schizophrenia, autism, global developmental delay, intellectual disability, constipation, tremor, and urinary incontinence who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 4 hours/day, 6 days/week, and 3 hours/day, 1 day/week. The patient underwent a universal assessment assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, shopping, transportation, and equipment management while extensive assistance with bathing, personal hygiene, dressing upper/lower body, and toilet use. With tasks of stairs and eating the patient was assessed with limited assistance while supervised with tasks of walking, locomotion, and transfer toilet. The patient was assessed as independent with the task of bed mobility. Notes from the assessment stated the patient was unable to participate in the assessment due to cognitive impairment, cognitive skills were moderately impaired, the patient had difficulty with short-term and procedural memory, and goes to training daycare center Monday to Friday 9 AM to 2:30 PM and receives speech training 2 days a week 3 PM to 6 PM. In addition, the assessment stated the patient had a decline in activities of daily living (ADL) status compared to 90 days ago and a deterioration in overall self-sufficiency compared to 90 days ago. The tasking tool estimated 24.07 hours/week of assistance needs. the patient's provider completed the Department of Health (DOH) 4359 form stating the patient needed assistance with personal care tasks and could not perform any skilled tasks or do any housekeeping. The insurer provided a final adverse determination denial notice stating the plan approval would end and they would review care again when a current invalid physician order was received. The denial also stated they had not received a copy of a recent physician's order within the past 2 months.

The health plan's determination is overturned.

PCS Level II Weekend/Holiday, CDPA Basic -15 Minutes is medically necessary for this patient. The patient requires assistance with all ADLs and Instrumental activities of daily living (IADLs) except bed mobility. The patient's physician provided DOH 4359 documenting the necessity for CDPAP services. The denial stated they had not received a physician's order but it was completed. The CDPAP services are medically necessary for this patient who requires assistance with IADLs and ADLs as documented by the Uniform Assessment System (UAS). 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, Personal Care Services (PCS) Level II weekend/holiday, Consumer Directed Personal Assistance (CDPA) Basic-15 minutes are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in her own home.