Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Mobility Issues
Treatment: Consumer and self-directed personal assistance services (CDPAS)- 35 hours a week 
The insurer denied Consumer and self-directed personal assistance services (CDPAS)- 35 hours a week.
The determination is overturned.

This is a female patient with a past medical history of hypertension, diabetes mellitus type 2, low back pain, urinary incontinence, asthma, and osteoarthritis who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 14 hours/week. There was a request to increase services and the patient underwent a telehealth assessment assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while limited assistance with tasks of stairs, transportation, bathing, and dressing lower body. The patient was assessed at independent with tasks of managing medication, phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. Notes from the assessment stated that the patient had just returned from Africa and needed services back, lived with her son and daughter in law in in a two bedroom apartment, had an open wound on the buttocks from burn injury, was unable to complete a timed 4 meter walk, and the patient's daughter was the primary care giver, and patient's son and daughter in law provided back up care.
The insurer sent an initial adverse determination denial notice denying request to increase CDPAP services stating the patient's daughter had requested more time for the patient but the nurse found no significant changes from the assessment completed before the patient joined the plan. The patient had told the plan that she had fallen and the plan recommended a shower chair to help with bathing, physical and occupational therapy, and that giving more aide hours cannot prevent falls or injuries. The insurer sent a final adverse determination denial notice continuing to deny request to increase CDPAP services stating the patient had a very supportive family, the patient had supplies to keep her clean and dry, the patient may benefit from receiving a bedside commode, and an aide could help her to the bathroom when present as needed. In addition, the denial stated time was not provided for companionship, safety, or supervision. The patient and the patient's medical provider the appealed denial decision. At issue is the medical necessity of consumer and self-directed personal assistance services (CDPAS)- 35 hours a week.

The services are medically necessary.

There was a request from the patient's family for an increase in CDPAP services and it was noted on the final adverse determination denial notice that the patient did require assistance with transfer toilet and toilet use despite noting the patient was independent at her assessment. The patient, therefore, 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. In addition, the patient's last assessment was performed via telehealth and likely underestimated the patient's care needs. The patient would require assistance outside of the hours that she had informal help which was 35 hours/week. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 35 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.