Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intellectual Disabilities, Osteoarthritis
Treatment:10 hours per day, 4 days per week total of 40 hours per week personal care services level 2 and 30 hours per week consumer directed personal assistance services (CDPAS)- combined 70 hours per week
The insurer denied 10 hours per day, 4 days per week total of 40 hours per week personal care services level 2 and 30 hours per week consumer directed personal assistance services (CDPAS)- combined 70 hours per week
The determination is overturned.

The patient has a history of intellectual disabilities and osteoarthritis who had been assigned personal care assistant (PCA) services 10 hours/day, 4 days/week, and Consumer Directed Personal Assistance Program (CDPAP) services 10 hours/week based on an assessment performed telephonically assessing the patient at total assistance with ordinary housework, managing finances, managing medication, and shopping while maximum assistance with tasks of meal preparation, phone use, and transportation. With the tasks of stairs, bathing, and dressing lower body the patient was assessed at extensive assistance while limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, and transfer toilet. The patient was assessed at supervision for tasks of toilet use, bed mobility, and eating. Notes from the  assessment stated the patient lived with her sister who made all of the patient's decisions and the family took care of the patient when the aide left. It was also noted the patient had moderately impaired cognitive skills. There was a request to increase CDPAP hours and the patient underwent a video assessment assessing the patient at total assistance with the task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. With the tasks of managing finances, managing medication, phone use, stairs, transportation, bathing, and dressing lower body the patient was assessed at extensive assistance while limited assistance with task of personal hygiene, dressing upper body, and toilet use. The patient was assessed at supervision with tasks of walking, locomotion, transfer toilet, and eating while independent with task of bed mobility. Notes from the assessment stated the patient had moderately impaired cognitive skills patient needed assistance with toileting, wiping after toilet use, and that the patient's sister stated the patient needed more assistance with personal care, cooking, and cleaning.
The insurer sent an initial adverse determination denial notice denying the request to increase CDPAP services. The patient's primary care physician (or provider) (PCP) had a follow-up visit with the patient and office note stated needs home care and cannot be left alone although the remainder of the note is illegible. The insurer sent a final adverse determination denial notice denying request to increase CDPAP services stating the extra hours requested were not medically necessary. The denial also stated the patient had 9 meals per week delivered to her home, that the patient did not need help getting into bed or turning in bed and there had not been any significant changes in her medical condition that would change her personal care needs. Lastly, the insurer noted health plans are not allowed to provide aide services for safety and supervision alone. The patient's PCP provided a letter noting the patient's medical diagnosis and the requirement of 24-hour care also noting the patient's condition was permanent, and the patient has no ability to perform any activities of daily living (ADLs) independently and cannot be left alone without supervision. The patient's PCP provided a denial appeal stating the patient has severe documented severe mental retardation and cannot safely be left unattended as this is a risk to both herself and others. The patient's sister appealed the denial decision noting the patient has severe mental retardation and cannot be left alone and needed constant supervision and was totally dependent on others for all needs. The insurer provided a summary of the patient's case.
At issue is the medical necessity of 10 hours per day, 4 days per week total of 40 hours per week personal care services level 2 and 30 hours per week consumer directed personal assistance services (CDPAS)- combined 70 hours per week.

Yes, the services are medically necessary.
The patient's medical provider and sister have documented the patient's medical diagnoses of intellectual disability with the inability to perform ADLs independently. The patient has a chronic condition. There will be no improvement in her condition. The assessment tool underestimated the patient's care needs as there would not have been improvement in patient's assistance needs when compared to the other assessment. Both of these assessments were video/telephone which also underestimated the patient's care needs. The patient has at least supervision with all tasks including walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The plan inappropriately assumed the patient has informal help outside of all provided PCA/CDPAP hours. The patient's PCP documented medical necessity of increased PCA/CDPAP hours. The requested increase in assistance is not solely for safety and supervision but to assist the patient with the safe completion of ADLs and (instrumental) IADLs. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, 10 hours per day, 4 days per week total of 40 hours per week personal care services level 2 and 30 hours per week consumer directed personal assistance services (CDPAS)- combined 70 hours per week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.