Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Traumatic brain injury (TBI), status post (s/p) cranial hematoma; grenade explosion, hand deformity and loss of movement of right wrist (s/p reconstructive surgery), chronic osteomyelitis of right foot/ankle

Treatment for CDPAS (Consumer Directed Personal Assistance Services) 7 days per week, 8 hours per day: 56 hours per week

The insurer denied coverage for CDPAS 7 days per week, 8 hours per day: 56 hours per week.

The denial is overturned.

This adult male has functional impairment due to various medical conditions and history of (h/o) trauma with persistent sequelae. He needs help with most daily activities. He lives with his partner/girlfriend. He receives daily assistance with instrumental activities of daily living (IADLs) and activities of daily living (ADLs) through personal care services provided as Consumer Directed Personal Assistance Services (CDPAS). His girlfriend is the CDPAS aide. The patient had been approved for and was receiving CDPAS 7 days per week, 8 hours per day, 56 hours per week. He was notified by the insurer that the CDPAS hours would be reduced to 7 days per week, 6 hours per day; 42 hours per week. 

The most recent Uniform Assessment System (UAS) provided for review was done. The functional status report indicates patient needs maximal assistance for housework, meal preparation and shopping; extensive assistance for managing medications; and limited assistance for finances, stairs, transportation, phone use. For ADLs, the patient needs extensive assistance for bathing, dressing, and eating; limited assistance is needed for personal hygiene and toilet use; setup help is needed for walking, locomotion, transfer toilet and bed mobility.

The patient has chronic pain which may be partly related to the trauma events noted. The neurologist reported that the patient has cervical and lumbar radiculopathy causing substantial pain. The patient has had cervical and lumbar discectomy, and epidural for lumbar radiculopathy. The neurologist noted physical therapy has had inconsistent response. The patient's lumbar symptoms include moderate to severe mid to lower back pain with radiation to right lower extremity with numbness and tingling. He was observed by the neurologist as having severe a limp and marked gait impairment (uses a cane). Straight leg raising was positive bilaterally. As per the UAS, the patient has difficulty moving to a standing position, most likely due to back pain and lower extremity symptoms. The patient's cervical spine symptoms include neck pain, right hand pain and weakness. Hand strength (neurologist's exam) was 4/5 (right) and 5-/5 (left); noting the patient's grip was affected. It is likely that the patient's impaired hand function is due to combined effects of cervical radiculopathy and effects of hand trauma (noted above).

The patient has chronic conditions (lumbar and cervical radiculopathy, osteoarthritis, sequelae from trauma and osteomyelitis of right foot). He has been treated with medications, physical therapy, and surgery. If a treatment or combination of treatments provide satisfactory pain relief, this could improve his functional ability, and he may not need as much assistance. However, the most recent available records (neurologist's) do not appear to indicate that the patient's pain has significantly diminished. He also has weakness and numbness due to spinal radiculopathy which also impair his function. There is no improvement of ADL function. The records provided for review do not provide a reason to decrease the patient's personal care hours (provided as CDPAS). 

The history and clinical information of the patient's medical and functional status supports the patient's need for assistance with most and probably all ADLs and IADLs, including activities that occur throughout the day (e.g., mobility, toileting, assistance with all meals). It does not appear prudent to decrease services at this time. 

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

The insurer's denial of coverage for Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 8 hours per day; 56 hours per week is overturned. Medical necessity is substantiated.