Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Alzheimer's dementia, history of closed traumatic subdural hemorrhage, primary generalized osteoarthritis

Treatment: Increase in her Consumer Directed Personal Assistance Program (CDPAP) services, for a total amount of 84 hours per week 
 
The insurer denied coverage for an increase in her Consumer Directed Personal Assistance Program (CDPAP) services, for a total amount of 84 hours per week 

The denial is modified

This female patient has experienced functional decline for daily activities associated with cognitive and physical impairments. The patient lives alone. She receives assistance from personal care services, provided as Consumer Directed Personal Assistance Program (CDPAP) services, 8 hours per day, 5 days per week, total of 40 hours per week. The uniform assessment system (UAS) reported patient also receives some informal help from friends. Request was made to increase CDPAP services to 12 hours per day, 7 days per week, 84 hours per week, which was denied. An external appeal was requested.  

The UAS functional status report for instrumental activities of daily living (IADLs) indicates patient is totally dependent for housework, she needs maximal assistance for meal preparation, shopping, managing medications; extensive assistance for managing finances, stairs, transportation; supervision for phone use. The UAS indicates patient needs supervision/cueing for all activities of daily living (ADLs).

The records provided for review indicate patient's cognition has declined over the past year. The UAS reported decision-making ability for daily tasks was minimally impaired (in some situations decisions were poor/unsafe and she needed supervision/cues at those times). She had short term memory impairment. For communication, her expression and comprehension were clear. There were no behavioral problems reported. There was significant decline by the time UAS.  She had extensive memory impairment including short term, procedural and situational memory. Friend reported patient was more confused. She was easily distracted. Her communication ability declined, as she had difficulty with word finding, finishing thoughts (needed prompting), and needed repetition/explanation to understand conversation. Regarding behavioral problems, there were some episodes of wandering reported.

During a routine day when the patient is home (plus any outside activity accompanied by the aide), CDPAP 12 hours per day is medically necessary to accommodate all the patient's care needs throughout the day. However, during the 5 hours the patient attends social day care one day per week (including transportation time), the patient is not receiving services from the CDPAP aide. Therefore, it is recommended that total weekly hours requested (84 hours per week) should be reduced by 5 hours to 79 hours per week. CDPAP aide schedule may include 12 hours per day, 6 days per week and 7 hours per day, 1 day per week; but that does not need to be determined at this time. The CDPAP aide schedule can be modified to provide optimal use of total CDPAP hours to meet the patient's care needs each day.

Recommendation is given to approve Consumer Directed Personal Assistance Program services 79 hours per week. Optimal schedule of daily hours (7 days per week) can be determined with the CDPAP aide(s) and patient.

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 an increase in her Consumer Directed Personal Assistance Program (CDPAP) services, for a total amount of 84 hours per week is modified. Medical Necessity is substantiated for 79 hours as detailed above.