Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied an Increase in Consumer Directed Personal Assistance Services (CDPAS)- 24 hours a week, 7 days a week (split shift), for a total of 168 hours. 
The denial is overturned. 

The patient is a male with a past medical history of diabetes mellitus type 2, hypertension, hyperlipidemia, glaucoma with vision loss, coronary artery disease, chronic kidney disease, benign prostatic hyperplasia (BPH), severe dementia, urinary incontinence, and bowel incontinence, who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services, 70 hours/week. The patient underwent assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and managing finances while maximum assistance with tasks of managing medication, phone use, and transportation. With tasks of stairs, bathing, personal hygiene, dressing upper body/lower body, transfer to the toilet, and toilet use while supervision with tasks of walking, locomotion, bed mobility, and eating. The patient lived alone, cognitive skills were severely impaired, vision was severely impaired, was unable to comprehend simple questions, wakes up in the middle of the night and will pace back and forth walking around his apartment, and family toilets him, changes his pullups, and performs hygiene.
At issue is an Increase in Consumer Directed Personal Assistance Services (CDPAS)- 24 hours a week, 7 days a week (split shift), for a total of 168 hours.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Increase in Consumer Directed Personal Assistance Services (CDPAS)- 24 hours a week, 7 days a week (split shift), for a total of 168 hours is medically necessary for this patient.
There is documentation from the patient's geriatrician and PCP of worsening cognitive and physical functioning with increased need with assistance with activities of daily living (ADL)s and Instrumental activities of daily living (IADL)s. These providers document a higher need of assistance with multiple ADLs compared to the assessment, specifically that the patient requires maximum to total assistance with transferring to the toilet and toilet use. Due to the patient's dementia, he has an abnormal sleep-wake cycle and is up throughout the night ambulating throughout his apartment. The patient requires at least supervision with walking and locomotion. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The geriatrician and PCP have noted adequate treatment with medications to control his medical conditions. The insurer has assumed the patient has informal help outside of the hours of CDPAP services. The patient's family is unable to assist the patient for informal care. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the plan's clinical standards, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 24 hours/day, 7 days/week, to total 168 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.
Therefore, the requested health service/treatment of Increase in Consumer Directed Personal Assistance Services (CDPAS) is medically necessary for this patient.