Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke/CVA- right sided weakness
Treatment: Home Health Care- Consumer Directed Personal Assistance Program (CDPAP): 11 hours per day - 6 day(s) per week - a total of 66 hours per week
The insurer denied Home Health Care- Consumer Directed Personal Assistance Program (CDPAP): 11 hours per day - 6 day(s) per week - a total of 66 hours per week.
The determination is overturned.

This patient has a medical history notable for stroke with resulting right sided weakness, cognitive impairment, diabetes, hypertension, and epilepsy. The patient is approved for 7 hours per day, 6 days per week (42 hours per week) of consumer directed personal assistance program (CDPAP). The patient and his care team requested an increase to 11 hours per day, 6 days per week (66 hours per week).
The patient's sister provided a letter of support for this appeal. The letter states that the patient's aide leaves at 1 in the afternoon, and they still need additional assistance. The patient's sister will help with things such as transfers, changing, and meal preparation. She is with the patient all day and typically cares for him during these off hours when his aide is not working.

A recent office visit note from the patient's physician was provided for review. The office visit note stated that they need additional help after the aide leaves, specifically, they need help with dinner preparation, eating, toileting, and showering. The patient underwent a fall recently, the day before the office visit; it occurred when they were attempting a transfer without assistance. The physician stated that the patient "is extremely limited with respect to activities of daily living (ADL)and needs constant help for activities of daily living (ADL).". The physician requests an increase in personal care service hours to meet the patient's functional needs.

A Uniform Assessment System (UAS) was completed on 2/9/23 and was available for review. The review was conducted via teleconference. The patient resides in a two-bedroom home with their sister. The patient's cognition is minimally impaired; they are alert and oriented to person and place only. Their recall is one-third at five minutes. For instrumental activities of daily living (IADL) they require total dependence for housework, finances, and medications. They require maximal assistance for all others. For activities of daily living (ADL) they require maximal assistance for bathing, dressing, toilet transfer, toilet use, and bed mobility. They require extensive assistance for hygiene, walking, and locomotion. They are occasionally incontinent of urine and stool. A task tool associated with the assessment recommended 7.5 hours per day to address the patient's personal care needs. At issue is the requested health service/treatment of Consumer Directed Personal Assistance Program (CDPAP): 11 hours per day - 6 day(s) per week - a total of 66 hours per week.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of Consumer Directed Personal Assistance Program (CDPAP): 11 hours per day - 6 day(s) per week - a total of 66 hours per week is medically necessary for this patient.

The patient requires hands-on assistance for all activities of daily living (ADL) and Instrumental activities of daily living (IADL), including transfers, locomotion, and toileting. The patient lives with their family who is involved and supportive. However, they have unmet personal care needs that the family is not able to provide for. The patient's recent fall while attempting transfer unassisted is evidence of an unmet personal care need. The physician notes document that they require additional care. The patient's needs are expected to be continuous and unscheduled, so the task tool may not adequately reflect the true level of need for the patient. It is therefore medically necessary to increase the patient's personal care hours to meet their needs.