Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall risk
Treatment: Customer directed personal assistance services from 40 hours per week to 70 hours per week.
The insurer denied Customer directed personal assistance services from 40 hours per week to 70 hours per week.
The determination is overturned.

This is a female patient with a past medical history of hypertension, gastroesophageal reflux disease (GERD), urinary incontinence, osteoarthritis, lumbar radiculopathy, obesity, polyneuropathy, osteoporosis, and bladder cancer who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 40 hours a week based on a video assessment assessing the patient at maximum assistance with the tasks of meal preparation, ordinary housework, stairs, shopping while extensive assistance with the tasks of managing finances, managing medication, transportation, bathing, walking, locomotion, transfer toilet, and toilet use. With the tasks of personal hygiene and dressing upper body the patient was assessed at limited assistance, set up help with the task of phone use, and independent with the tasks of bed mobility and eating.
Notes from the meeting stated the patient lived alone and the tasking tool assessed 34.31 hours/week. The patient was hospitalized for ventral/incisional hernia repair. There was a request to increase the CDPAP services and the patient underwent another assessment  assessing the patient at maximum assistance with the tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing medication, stairs, transportation, equipment management, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed with limited assistance with tasks of personal hygiene and dressing upper body while supervision with tasks of managing finances and phone use. With the tasks of bed mobility and eating, the patient was assessed at independent. Notes from the assessment stated the patient lived in a one bedroom apartment with her daughter and the tasking tool estimated 37.46 hours/week.
The patient's medical provider sent a letter requesting an urgent increase in hours of home care for the patient due to her rapidly deteriorating mental state, physical health, and functional status. The letter also stated that the patient had urinary incontinence in which she wears a diaper and requires multiple daytime and nighttime changes of soiled diapers and linens to prevent skin irritation and rash. In addition, the letter stated the patient required human assistance with wheelchair movement, mobility, and safety transfers. Lastly, the letter recommended and stated it was medically necessary for the patient to have 10 hours of home care daily, 7 days/week.
The insurer sent an initial adverse determination denial notice partially denying the request to increase CDPAP services stating the service was not medically necessary but increasing to 42 hours/week.The insurer sent a final adverse determination denial notice continuing to partially deny the request to increase CDPAP services stating the patient the patient was able to contact 911 and declined a personal emergency response system (PERS), the patient lived together with her daughter and her cousin was her CDPAP worker, the patient had a hospital bed, rollator, shower chair, and commode, the patient might benefit from physical therapy (PT), and the patient could schedule service hours to better meet her needs. The insurer sent a case summary outlining the responses in the initial and final adverse determination denial notice. The patient's health care advocate sent a letter stating the insurer incorrectly noted that the patient lived with her daughter when the patient did not. The healthcare advocate also noted the patient could not change her diaper or get out of bed on her own. At issue is the medical necessity of customer directed personal assistance services from 40 hours per week to 70 hours per week.

There is documentation from the patient's medical provider of medical necessity for increased CDPAP services. The plan incorrectly documented that the patient was living with her daughter assuming the daughter was able to provide more informal support. The patient requires at least extensive assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient requires activities of daily living (ADLs)/ Instrumental activities of daily living (IADLs) assistance outside of the hours she has informal help. 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, CDPAP services 70 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.