Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, Congestive Heart Failure, Coronary Artery Disease

Treatment: Consumer directed personal assistance services (CDPAS), a total of 82 hours per week

The insurer denied coverage for consumer directed personal assistance services (CDPAS), a total of 82 hours per week

The denial is upheld 

This case involves a patient that lives with their spouse. The patient requires extensive assistance with bathing, personal hygiene, dressing, walking, toilet transfers, bed mobility, and eating. The patient requires maximal assistance with meal preparation, shopping, and housework. The patient is frequently incontinent for bladder and infrequent for bowel. There were no reported skin breakdowns. The patient's diagnoses include diabetes, congestive heart failure, coronary artery disease, shortness of breath, nausea, and dizziness. The patient was admitted to the hospital with acute onset of left sided weakness, diagnosis of transient ischemic attack. Medications include Bumetanide, Clopidogrel, Crestor, Eliquis, Gabapentin, Hydralazine, Novolog Insulin, Isosorbide, Jardiance, Losartan, Lutein, Metformin, Metoprolol, Rocklatan, Rosuvastatin, Spironolactone, Timolol, Tylenol, Vitamin D3. The assessor indicated the patient could not be left alone safely. The record indicates the patient is left alone for five hours between when the patient's husband leaves for work and when the aide arrives. 

The patient was given a mini mental exam and scored an 18/30. The patient had one fall in the last 30 days without injury. The patient receives 14 meals a week. The patient received cardiac stents. The husband works and the patient is alone for five hours between his departure and care provider's arrival. There are no behavioral issues. 

The patient was given another mini mental exam and scored 25/30. An assessment performed noted a change in care needs for activities of daily living, medication counts, cardiorespiratory condition, and cognitive loss. 

The patient was admitted to the hospital with acute onset of left sided weakness, diagnosis of transient ischemic attack. 

A letter was sent to the patient noting the hours given under the last authorization or reauthorization were still enough to meet the patient's needs. The appeal was denied. 

The consumer directed personal assistance services (CDPAS) program is intended to permit chronically ill or physically disabled individuals receiving home care services under the medical assistance program greater flexibility and freedom of choice in obtaining such services.

The review of literature and clinical notes submitted reveals the patient currently receives 47 hours per week of Personal Assistance Services. The care manager has arranged time for a skilled nursing visit, physical and occupational therapy, and social work visits to provide additional support. The hours of assistance should be re-arranged so that the patient is not left home alone. As such the decision to maintain the current 47 hours per week of personal assistance services is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for consumer directed personal assistance services (CDPAS), a total of 82 hours per week is not substantiated.