Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Falls, Mobility issues
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Services: 11 Hours per Day, 5 Days per Week; 7 hours per day 2 days per week for a Total of 69 Hours per Week
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: 11 Hours per Day, 5 Days per Week; 7 hours per day 2 days per week for a Total of 69 Hours per Week
The determination is overturned.

The patient has a past medical history of hypertension, congestive heart failure, atrial fibrillation, chronic anticoagulation, large abdominal hernia, osteoarthritis, osteoporosis, urinary incontinence, diabetes mellitus (DM) type 2, gastroesophageal reflux disease (GERD), and hypothyroidism who had been assigned consumer directed personal care assistance program (CDPAP) services 7 hours/day, 7 days/week, to total 49 hours/week based on a telephonic assessment tool assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, shopping, and locomotion while maximum assistance with tasks of medication management, stairs, transportation, bathing, dressing lower body, walking, and transfer toilet. The patient was assessed at extensive assistance with the tasks of phone use, equipment management, personal hygiene, dressing upper body, toilet use, and bed mobility while independent with the task of eating.
The patient had a fall while walking with a walker. The patient had an office visit with the primary care physician (PCP) for follow up of multiple falls at home. The office note stated the patient was essentially wheelchair bound and not able to ambulate even with a walker and had 5-6 falls in the last two weeks. The provider discontinued her anticoagulation medication.

The patient's cardiologist provided a letter stating the patient was having frequent falls and required assistance due to high risk of falls and mobility issues. With the request to increase services the patient underwent a telephonic assessment tool assessing the patient at total assistance with the tasks of ordinary housework, managing finances, shopping, transportation, equipment management, and locomotion while maximum assistance with tasks of meal preparation, managing medication, stairs, bathing, dressing upper/lower body, walking, transfer toilet, and toilet use. The patient was assessed at extensive assistance with the tasks of phone use, personal hygiene, and bed mobility while independent with the task of eating. Notes from the assessment noted the daughter reported a decline in the member's ability to complete activities of daily living (ADLs) due to loss of balance and dexterity related to medical problems and that the patient was becoming wheelchair-bound due to osteoarthritis and a very large abdominal hernia. The notes also stated the patient had oxygen and this was managed by a caregiver, the patient was wheelchair-bound and was pushed by others, the patient could stand and walk a few steps for transfers when given 2 person assistance, and the patient required significant weightbearing help for dressing, personal hygiene, bathing, and toilet use.

The insurer provided an initial adverse determination denial notice denying a request to increase CDPAP service hours and recommended certified home health agency evaluation for skilled nursing and physical therapy services and enrollment into a fall risk prevention program. The patient was evaluated and services were started with skilled nursing and physical therapy in the home.

The insurer provided a final adverse determination denial notice denying the request to increase CDPAP services stating it was not medically necessary and the patient did not meet criteria. The denial also stated hours were not provided when tasks were not being performed or for safety monitoring and supervision. The patient was seen by a physical therapist in her home and their notes stated the patient was unable to arise without help, was unsteady with immediate standing balance, when nudged begins to fall, was unsteady with eyes closed, used discontinuous steps and was unsteady with turning 360 degrees, was unsafe sitting down, and was high risk on Tinetti score. The physical therapy notes also stated the patient had chronic bilateral shoulder pain, was only able to ambulate a few feet with a 2 wheeled walker, the patient reported bowel and bladder incontinence that the patient was not able to control or clean without assistance, the patient's daughter was not able to be home all day, recommended an increase in home health care attendant hours for 24-hour assistance, and to continue therapy services to work toward goals.

The patient's cardiologist provided a letter stating the patient required assistance with her day-to-day activities and health. Another cardiology provider sent a letter stating the patient should not be left alone and required 24-hour supervision and care and the patient required assistance with all of her activities of daily living and was unable to take her medication on her own. The letter also stated she had multiple falls and was at high risk for falling again and recommended that she not be left alone for any extended period of time. The patient and her family appealed the denial decision and provided a letter stating virtual assessment made by the nurse was incorrect, the patient was homebound, the patient needed 2 person assist for transfers in and out of transportation to and from the Medical Doctor's (MD) office, the patient did not comprehend questions and needed more time to process them, the patient was not self directing, the patient could not lift her self up after falling and waits on the floor until someone comes home to pick her up, had difficulty getting up from bed to walker, and from walker to commode and has slid down on the floor, was unable to inject herself medicines during the day, was unable to eat lunch left on the table for her, could not groom herself, could not dress herself, had difficulty pulling up undergarments after toileting, and soiled her diaper when left unattended and was unable to clean herself and change herself and will sit in feces until someone comes home to help clean her and change her.
At issue is the medical necessity of a requested increase in Consumer Directed Personal Assistance Program (CDPAP) Services: 11 hours/day, 5 days/week, and 7 hours/day, 2 days/week to total 69 hours/weekfor a Total of 69 hours per week.

The services are medically necessary.

The patient has chronic and progressive medical conditions including diastolic heart failure, a large abdominal hernia, osteoarthritis, and frequent falls with documented worsening in functional status. The patient is also now on oxygen therapy. Documentation provided by the visiting nurse service stated the patient was now had bowel incontinence. The patient requires at least extensive assistance with all ADLs except for eating. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The patient's current CDPAP hours and/or medical supplies and/or adaptive equipment are not sufficient to meet the patient's ADL/Instrumental activities of daily living (IADL) care needs. The requested increase in CDPAP hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's family is not able to provide the same level of 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 11 hours/day, 5 days/week, and 7 hours/day, 2 days/week to total 69 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.