Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colon Cancer
Treatment: Consumer directed personal assistance program (CDPAP): 8 hours per day- 7 days per week- a total of 56 hours per week
The insurer denied Consumer directed personal assistance program (CDPAP): 8 hours per day- 7 days per week- a total of 56 hours per week.
The determination is upheld.

This is a male patient with a medical history notable for stage 4 colon cancer. The patient is approved for 4.5 hours per day, 7 days per week (31.5 hours per week) of consumer directed personal assistance program (CDPAP). The patient and his care team requested an increase to 8 hours per day, 7 days per week (56 hours per week) and this request was denied by the health plan.
The request for additional hours states the following: "I require more hours with an aide. My stage four colon cancer has gotten progressively worse. I am unable to use the bathroom, shower, cook, eat, dress myself alone. I also suffer from severe depression which makes it even more difficult to be alone."
A letter of support was provided for this appeal (the author is not listed). The letter states that the patient has stage 4 colon cancer and is undergoing chemotherapy, which has resulted in decline in physical and cognitive status. He needs personal care assistance with hygiene, bathing, toileting, meals, and medications. He needs assistance with transportation to his treatment sessions which can be 5-6 days per week.  
Records detail the patient's chemotherapy regimen for treatment of his stage 4 colon cancer. There are notes from hospitalizations for small bowel obstruction and neutropenic fever. Outpatient oncology and palliative care office visit notes were also provided and reviewed in detail.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives with his sister who serves as his CDPAS. He was alert and oriented times three; cognition was minimally impaired. Recall was 1/3 at five minutes. He has periods of forgetfulness. For his Instrumental activities of daily living (IADLs), he requires total dependence for housework and finances. He requires maximal assistance for meal preparation and shopping. He requires extensive assistance for transportation and stairs. For his activities of daily living (ADLs), he requires extensive assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. He requires limited assistance for dressing upper body. He is independent for hygiene, bed mobility, and eating. He ambulates with a walker with weight bearing assistance. He has bilateral nephrostomy tubes in place which visiting nurse services check every 3 days. He is infrequently incontinent of stool (no episodes over the prior 3 days, but has had episodes following chemotherapy). There were no falls in the previous 90 days. A task tool associated with the assessment recommended 4.5 hours per day (31.5 hours per week) to address his personal care needs. At issue is the medical necessity of consumer directed personal assistance program (CDPAP): 8 hours per day- 7 days per week- a total of 56 hours per week.

The requested health service of consumer directed personal assistance program (CDPAP): 8 hours per day-7 days per week- a total of 56 hours per week has not been demonstrated to be medically necessary for this patient.
The patient is currently approved for 4.5 hours per day (31.5 hours per week) which is what the task tool recommends to address his personal care needs. There is no discussion of unmet personal care needs. The request states that the hours are to help with toileting, showering, cooking, dressing, and transportation. These needs are accounted for in the tasking tool. There is also a request for additional hours due to depression; this is not an allowable level 2 personal care function in the absence of other personal care needs. Therefore, there is not clearly demonstrated medical necessity for an increase in personal care hours.