Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, imbalance, hypertension, atrial fibrillation

Treatment: increase in Consumer Directed Personal Care Assistance Services from 22 hours per week to 112 hours per week

The insurer denied coverage for increase in Consumer Directed Personal Care Assistance Services from 22 hours per week to 112 hours per week. The denial is reversed.

This patient is a female who lives alone in apartment. Due to various health problems the patient needs assistance for most IADLs and several ADLs. She was approved for consumer directed personal assistance services (CDPAS) 22 hours per week, with her granddaughter as the aide. The patient's functional assessment in the UAS for the final quarter of 2019 indicates patient needs extensive or maximal assistance for all IADLs, except phone and managing medications (setup help only). For ADLs, the UAS reports patient needs limited assistance for bathing, personal hygiene and dressing; supervision for walking/locomotion; independent with setup help for toileting, bed mobility and eating. As per UAS, the patient has no significant cognitive deficits: decision making is independent, no memory problems, self-directing, manages her finances, can describe and activate emergency plan; Mini Mental Status Exam (MMSE) 30/30.

Therefore, the primary reason for the patient's functional impairment and need for assistance with daily activities is due to physical symptoms resulting in limited or unstable mobility. The UAS describes various symptoms and physical impairments including: slow unsteady gait; uses cane and holds on to walls and furniture for support; difficulty walking for extended time (farthest distance walked without sitting down: 15 ft); limited ability to bend, lift, carry; pain in shoulder causing difficulty with extending, reaching, raising; pain also noted in knees and lower back; difficulty moving to standing position unassisted. The patient has osteoarthritis, which is a common cause of functional decline in older people. It is likely that some of her symptoms including knee and back pain may be due to arthritis. Patient also has bilateral carpal tunnel syndrome, status post surgery to right hand. At the time of the UAS she still had functional limitations due to recent carpal tunnel surgery.

The patient has multiple risk factors for falls including unsteady gait, arthritis, dizziness, incontinence, chronic pain, advanced age, h/o falls, use of medications associated with fall risk (e.g. antihypertensive drugs, diuretics).  When older people fall there is a higher risk of serious injury (e.g. fractures, head trauma), increased morbidity and increased risk of death. Traumatic brain injury is associated with worse outcome in the elderly. Fall prevention is a priority for the patient's care plan. It is acknowledged that there are few (if any) interventions that can prevent all falls; but the purpose of fall assessment is to determine risk and identify how the patient's mobility that can be made safer. Considering the patient's difficulty with mobility as identified in the UAS, and with recent history of falls (including head injury) reported by the physician, it appears that providing some assistance with ambulation is indicated.

The request for increase of CDPAS is for 16 hours per day, 7 days per week. The allocation of hours will be determined in collaboration the patient and possibly with family members to maximize benefit. Consumer Directed Personal Care Assistance Services 16 hours per day, 7 days per week, total of 112 hours per week are medically necessary. The health plan did not act reasonably with sound medical judgment.

Based on the above, the medical necessity for the requested increase in Consumer Directed Personal Care Assistance Services from 22 hours per week to 112 hours per week is substantiated.  The insurer's denial is reversed.