Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease with bypass grafts and stent placement, hyperlipidemia, hypertension, type 2 diabetes mellitus, seizure. 

Treatment: Consumer directed personal assistance services (CDPAS) of 12 hours per day, 7 days per week for a total of 84 hours per week. 

The insurer denied coverage for consumer directed personal assistance services (CDPAS) of 12 hours per day, 7 days per week for a total of 84 hours per week. 

The denial is overturned. 

The patient has extensive medical history including several conditions contributing to functional decline resulting in dependence on caregivers for assistance with most daily activities. The patient lives alone. He has some informal help from family, but primarily relies on personal care services, provided as Consumer Directed Personal Assistance Services (CDPAS). He is currently receiving CDPAS 35 hours per week; granddaughter and daughter-in-law are CDPAS aides. Request was made for increase of CDPAS to 84 hours per week, which was denied. 

There are a few other concerns regarding assistance for some routine daily activities. In the physician's note, the patient reported he is unable to get out of bed by himself; he is unable to lift his head. This indicates the patient is in bed until the CDPAS aide arrives, and so it is necessary for the aide to arrive in the morning, as the patient cannot get out of bed or perform any routine ADLs (activities of daily living) without assistance. It also indicates the patient may not be able to use a bedside commode, as he would have to get up from bed unassisted when alone at night. If a commode is not a satisfactory option, the patient either must be able to use a urinal at night (uncertain whether his hand can firmly hold the urinal and place it down without spilling), or he has episodes of incontinence through the night. The patient needs assistance with evening ADLs, before going to bed including dressing, personal hygiene, toileting. It is not clear how these tasks are performed with CDPAS only 5 hours per day. 

MLTC (Managed Long Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. When the patient needs assistance with toileting, incontinence care, transfer, walking, food/fluids, this is not stand-alone safety supervision. This is assistance the patient needs for proper and safe completion of daily activities. These care needs must be considered in the determination of the patient's personal care service hours. 

The patient's care needs extend through the entire day including all routine IADLs (instrumental activities of daily living) and ADLs, meals (preparation, service and assistance/supervision with eating for all meals), mobility, toileting and incontinence care which occurs at unscheduled, recurring times of the day and night. Increase of services is medically necessary to help prevent adverse health and safety events, e.g., falls/injury, incontinence associated skin damage, nutritional decline, dehydration, aspiration. There is some concern about the patient's need for assistance during night hours, especially for toileting and out-of-bed mobility. It is not known if the family has other arrangements for nighttime assistance. Recommendation is given for CDPAS services 84 hours per week. The patient will benefit from having caregiver assistance for daily activities from morning until evening when he is most active and in need of more frequent care. 

Consumer Directed Personal Assistance Services 84 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for the requested Consumer Directed Personal Assistance Services (CDPAS) of 12 hours per day, 7 days per week for a total of 84 hours per week is substantiated. The insurer's denial is overturned.