Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Consumer directed personal assistance services 24 hours per week
The insurer denied Consumer directed personal assistance services 24 hours per week.
The determination is overturned.

This is a male patient with a past medical history of osteoarthritis, spinal stenosis, depression, lumbar radiculopathy, cervical radiculopathy, hypertension, and hyperlipidemia who had Consumer Directed Personal Assistance Program (CDPAP) services 8 hours/week. There was a request to increase services and the patient underwent an assessment, assessing the patient at total assistance with the task of ordinary housework while maximum assistance with task of meal preparation and shopping. The patient was assessed at limited assistance with tasks of transportation, bathing, and dressing upper/lower body while independent with tasks of managing finances, managing medication, phone use, stairs, personal hygiene, walking, locomotion, transfer toilet, toilet use, mobility, and eating. A provider completed the medical review and practitioners order form stating the patient lived alone, had limited range of motion in the upper extremities, had difficulty bending over due to low back pain, had unsteady gait and falls. The patient's symptoms of pain get worse with prolonged walking, standing, bending, and exerting. The insurer sent a final adverse determination denial notice denying request to increase Consumer Directed Personal Assistance Services (CDPAS) hours stating review of the M11 Q form completed by the patient's doctor and the nurses uniform assessment supported approval of 8 hours/week of CDPAP services and the request for 24 hours/week was not medically necessary. At issue is the medical necessity of Consumer directed personal assistance services 24 hours per week.
The services are medically necessary. There is documentation the patient requires assistance with meal preparation, ordinary housework, shopping, transportation, bathing, and dressing upper and lower body. There is also documentation that the patient has intermittent worsening pain that limits his ability to walk, stand, bend, or exert. The severity of his pain and assistance needs with activities of daily living (ADLs) are unpredictable and the assessment underestimated his level of assistance with ADL and Instrumental activities of daily living (IADL) tasks. In addition, there is documentation that the patient requires assistance getting to physical therapy 2 times per week for which he requires transportation assistance. Although the tasking tool noted the patient was independent with walking and locomotion as well as transfer toilet the patient's assistance needs were underestimated as his pain exacerbates with prolonged walking, standing, bending, and exerting. 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 24 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 his own home.