Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, senile dementia, hypertension, thyrotoxicosis, and urinary incontinence.

Treatment: Consumer Directed Personal Assistance Program (CDPAP)- 12 hours per day, 7 days a week- total of 84 hours a week.

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP)- 12 hours per day, 7 days a week- total of 84 hours a week.

The denial is overturned.

The patient has a past medical history of Parkinson's disease, senile dementia, hypertension, thyrotoxicosis, and urinary incontinence.  The information provided noted that the patient requires maximal assistance for dressing her upper body, lower body, personal hygiene, walking, locomotion, bathing, toilet transfer, and toilet use, as well as meal preparation capacity and medication management capacity.  The patient required assistance for shopping and transportation.  The patient had total dependence for ordinary housework.  The patient required extensive assistance with bed mobility and eating.  The patient was frequently incontinent of the bowel and bladder.  The records indicated the patient lives alone in an elevator-accessible apartment building.  The patient had minimally impaired cognitive skills and had some short-term memory problems.  The patient's status was noted to have declined over the past 90 days due to an increase in pain in the limbs, increased fatigue, and lack of control of muscle movement.  The records indicated the patient had a recent fall on where a family member found her on the floor alone after getting up to go to the bathroom.  The patient was requesting more help at home.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

Consumer Directed Personal Assistance Program (CDPAP) - 12 hours per day, 7 days a week- total of 84 hours a week is considered medically necessary for this patient.

The appeal letter from the provider noted the patient's condition had been deteriorating.  The patient's gait was unsteady lately.  The patient had difficulty using her hands and legs secondary to arthritis.  Mental status had been rapidly deteriorating.  The patient got confused and disoriented.  The patient required total assistance with activities of daily living including bathing, dressing, grooming, toileting, skin care, transferring from the bed to the walker, and accompanying and supporting the patient while she ambulated with a walker.  The patient also needed assistance with shopping, laundry, cleaning, meal preparation, and a reminder to take her pre-poured medications.  The provider also noted that patient lives alone and was at high risk for falls.  The documentation supports that the patient requires maximal assistance for some activities of daily living and had total dependence for ordinary housework.  She required extensive assistance with bed mobility and eating.  The patient was frequently incontinent of the bowel and bladder.  The patient lives alone in her apartment and her status had declined. The patient had a recent fall. For the patient's safety, it is appropriate for her to receive the requested care. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Consumer Directed Personal Assistance Program (CDPAP)- 12 hours per day, 7 days a week- total of 84 hours a week is overturned. Medical Necessity is substantiated.