Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bedbound/Mobility Issues, History of Falls, Dementia, Pressure Ulcers.
Treatment:  Consumer Directed Personal Assistance Program (CDPAP) Services: Live-In per Diem, 7 Days per Week (Total of 7 Days per Week).

The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: Live-In per Diem, 7 Days per Week (Total of 7 Days per Week).  The health plan's determination is overturned.

The patient is a female with a past medical history (PMH) of dementia, hypertension, coronary artery disease, osteoarthritis, bowel and bladder incontinence and diabetes mellitus type 2. She also has a PMH of osteoporosis, gastroesophageal reflux disease (GERD), hyperlipidemia, lower extremity pressure sores and peripheral vascular disease. The patient had Consumer Directed Personal Assistance Program (CDPAP) services for 10 hours a day, 7 days a week. The assessment showed the patient at a total assistance level with the tasks of meal preparation, ordinary housework, managing finances, phone use, shopping, and locomotion. She required maximum assistance with the tasks of managing medication, stairs, bathing, dressing lower body, walking, toilet transfers and toilet use. For the tasks of personal hygiene, dressing upper body, bed mobility, and eating the patient was assessed at an extensive assistance level. The tasking tool estimated 52.5 hours a week.

The patient was hospitalized with Escherichia coli (E. coli) diarrhea, a urinary tract infection (UTI), and right lower extremity cellulitis. The patient's primary care physician (PCP) provided a letter stating that the patient had a history of a fall injury, multiple pressure ulcers on her bilateral legs and feet, diabetes mellitus, hypertension, Alzheimer's, osteoporosis, and osteoarthritis. The provider also noted the patient was unable to take care of herself and needed home health aide services 24 hours a day. 

The patient underwent another assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, stairs, shopping, bathing, dressing lower body, and toilet use. The patient was at a maximum assistance level with the tasks of bed mobility and eating. For the task of dressing upper body the patient was assessed at extensive assistance, while it was noted that activities of walking, locomotion, and transfer toilet did not occur. The notes from the assessment stated the patient was unable to express goals of care, she lived alone, she had a decline in her activities of daily living (ADL) status in the last 90 days and had a deterioration of her overall self-sufficiency in the last 90 days.

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 Live-In per Diem, 7 Days per Week (Total of 7 Days per Week) are medically necessary for the patient.  There is documentation of worsening physical and mental functioning following the patient's hospitalization. The patient's PCP and hospice director documented the medical necessity for increased CDPAP services. The patient requires assistance with transfers to the toilet and for toilet use and does not walk since she is bedbound. The patient, therefore, has unpredictable and unscheduled care needs that span a continuum of time, and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies.
The plan incorrectly assumed that the daughter could provide informal help and 24-hour care. 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.