Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hereditary spastic paraplegia, hypertension, and hyperlipidemia.

Treatment CDPAP (Consumer Directed Personal Assistance Services) services, 10 hours per day, 5 days per week (Monday through Friday), total 50 hours per week.

The insurer denied coverage for CDPAP services, 10 hours per day, 5 days per week (Monday through Friday), total 50 hours per week.

The denial is overturned. 

The patient is a male with significant functional impairment primarily due to hereditary spastic paraplegia. He needs assistance with most Instrumental activities of daily living (IADLs) and activities of daily living (ADLs). He receives personal care services 30 hours per week through Consumer Directed Personal Assistance Services (CDPAS). The patient's brother lives with the patient and serves as CDPAS aide. The patient indicated in a letter that 30 hours per week is insufficient to meet his daily needs. The patient's physician wrote a letter which included recommendation for services 40 hours per week. 

As a result of the patient's neurologic condition (HSP), pain (knee pain/stiffness, muscle cramps/spasm), and some degree of memory impairment, his ability to perform most daily activities is impaired. He needs help with most daily tasks, including routine IADLs (preparation/service of 3 meals per day; most household related tasks; medication reminders); routine morning and evening ADLs (bathing, dressing, personal hygiene); ADLs that occur at various unplanned times of the day (all toileting related tasks, wheelchair mobility outdoors and at times, indoors). The patient also may need his caregiver to assist with certain exercises he performs to help prevent development of contractures. Periodic repositioning from wheelchair may be necessary for pressure relief and possibly to relieve discomfort from various sources of pain. ADLs requiring weight-bearing assistance are physically demanding and need more time to complete.

Considering the information provided for review, it is medically necessary for the patient to have assistance at various times throughout the day for most daily activities. Although there are no daily activity logs provided for review, it appears that CDPAS 30 hours per week is not sufficient for the level of assistance and frequency of care the patient needs.

The maximum number of CDPAS hours that can be approved from this review is based on the hours requested, as reported in the FAD (final adverse determination); in this case 50 hours per week. With consideration of all the issues impacting the patient's health and safety, it is medically necessary and, in the patient's, best interest to have caregiver assistance for a more extended period of time. CDPAS 50 hours per week should be allocated to provide assistance during times of the day, and days of the week when the patient needs the most assistance. 

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

The insurer's denial of coverage for Consumer Directed Personal Care Assistance (CDPAP) services, 10 hours per day, 5 days per week (Monday through Friday), total 50 hours per week is overturned. Medical Necessity is substantiated.