Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, heart transplant, and coronary heart disease 
Treatment: Consumer directed personal assistance services 

The insurer is denied coverage for consumer directed personal assistance services. 

The denial is reversed. 

This patient a female with a history that included hypertension, type 2 diabetes mellitus, hyperlipidemia, coronary heart disease, systolic and diastolic heart failure, heart transplant. The UAS indicates she lives at home with a child (a daughter was on the phone during the UAS but it is not clear whether she is the child who lives with the patient). In addition to the heart transplant, the patient has other medical conditions that affect her functional status; resulting in the need for assistance with most daily activities. The patient had been receiving Consumer Directed Personal Assistance Services (CDPAS) 70 hours per week. Following re-assessment (UAS), the insurer reduced the patient's CDPAS to 35 hours per week, which was upheld on appeal. An external appeal was requested. 

There is limited information about the patient's functional status before heart transplant and the following year. The patient was receiving 70 hours CDPAS (most recent approval was for as per insurer's denial letter); and so it appears she needed considerable assistance with daily activities. Heart transplant patients often have reduced exercise capacity compared to the general population. Exercise programs can help but there are variables, including co-existing conditions. The extent and effect of rehabilitation for the patient post-transplant is not noted in the available records. 

The patient most likely had a long period of time when her functional capacity was poor due to end stage heart failure prior to transplant. The records from the physician's office describe several post-transplant complications. The patient's medical condition appeared relatively stable at the time of the office visit, but she still has significant symptoms due to various problems including: decreased exercise capacity/poor endurance and weakness (post heart transplant); tremors (possibly due to medication); chronic pain (possibly due to arthritis), impaired vision. The UAS indicates the patient needs physical assistance from a caregiver in order to perform ADLs and IADLs effectively and safely. The patient still has significant health risks related to her post-transplant status; e.g. risk of infection (immune suppression); diabetes/glucose control and osteoporosis risk (patient is taking prednisone); risk of further kidney damage (prograf, dehydration).  It is medically necessary that the patient's care plan for daily activities serves to minimize health and safety risks; e.g. assistance with mobility-related ADLs to reduce risk of falls; provide assistance and easy access to all her meals and fluids throughout the day; assist with mobility to the toilet to minimize further incontinence. 

The patient has various medical conditions associated with substantial functional impairment that require a high level of assistance for most daily activities, including ADLs that occur throughout the day at unscheduled times (transfers, walking, toileting). Therefore, it is medically necessary for a personal care aide (in this case CDPAS) to be present to assist the patient with daily activities during day time hours when the patient is most active. 

Consumer Directed Personal Assistance Services, 70 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for Consumer Directed Personal Assistance Services (CDPAS) 70 hours per week is substantiated. The insurer's denial is reversed.