Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hemorrhagic Stroke

Treatment: Consumer Directed Personal Assistance Program (CDPAP): 8 hours per day- 7 days per week- for a total of 56 hours per week

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP): 8 hours per day- 7 days per week- for a total of 56 hours per week.

The denial is upheld. 

This case involves a patient with a subject for review for the denial of coverage for Consumer Directed Personal Assistance Program (CDPAP): 8 hours per day- 7 days per week- for a total of 56 hours per week.

A Client Task Sheet was completed and 14 hours per week of CDPAP is required to meet the patient's needs.

According to the physical therapy (PT)/occupational therapy (OT) discharge summary, the patient needs supervision with walking, bed mobility, getting in and out of bed/chair, and physical assistance with stair climbing. The patient also needs supervision in getting in and out of tub/shower and toileting, bathing. The patient is independent with dressing, feeding, and grooming.
 
A Uniform Assessment System - New York, Comprehensive Community Health Assessment Report was completed.  A second Client Task Sheet was completed and it was determined that 27.5 hours per week of CDPAP is required to meet the patient's needs.

This is the case of a patient who lives with their spouse with a diagnosis of hypertension (HTN), rheumatoid arthritis (RA), and hemorrhagic stroke. The patient is alert and oriented (times) x3 (person, place, time) and forgetful at times, has minimal difficulty with hearing, and has adequate vision. Per the assessment, the patient requires maximal assistance with meal preparation, managing medications, stairs, shopping, transportation, bathing, walking, and locomotion. Extensive assistance is needed for dressing the upper body, dressing the lower body, transfer to toilet, and toilet use. The patient is totally dependent for ordinary housework and managing finances. The patient requires set-up help with phone use, and is independent with mobility, and eating. The caregiver reported that the patient's health condition significantly declined due to RA and stroke. The patient also reported that they are infrequently incontinent of bladder and denied bowel incontinence. No falls were reported, shortness of breath (SOB) is controlled with rest, and the patient's pain is controlled with their current medication regimen.  The patient requested an increase in CDPAP services because they had a stroke and was admitted in the hospital, has difficulty with speech, coordination and understanding. 

Based on the review of all the information received that includes Uniform Assessment System - New York, Comprehensive Community Health Assessment Report, letter of medical necessity, and the medical records from Seacrest Nursing & Rehabilitation Center, it was determined that the approved CDPAP of 5.5 Hours/Day - 7 day(s) per week - Total of 38.5 hours per week is sufficient to meet the patient's needs. The patient's spouse is supportive in all aspects of care and is available to help and guide the patient to accomplish their needs, activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Further, the member has a cane, shower chair, shower grab bar, walker, walker (seated rollator) and incontinent supplies help manage their needs. As such, the denial of coverage for Consumer Directed Personal Assistance Program (CDPAP): 8 hours per day- 7 days per week- for a total of 56 hours per week is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Consumer Directed Personal Assistance Program (CDPAP): 8 hours per day- 7 days per week- for a total of 56 hours per week is not substantiated.