Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease (CAD), congestive heart failure (CHF), atrial fibrillation (A fib), chronic obstructive pulmonary disease (COPD) and severe
knee arthritis.
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) 8 Hours Per Day, 7 Days  A Week A Total of 56 Hours Per Week.

The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP) 8 Hours Per Day, 7 Days  A Week A Total of 56 Hours Per Week.  The denial is overturned.

This is a male patient with conditions including coronary artery disease (CAD), congestive heart failure (CHF), atrial fibrillation (A fib), chronic obstructive pulmonary disease (COPD) and severe knee arthritis.  He lives with his daughter in a three bedroom apartment.  The daughter/PA provides assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs).  The patient is appealing the denial of 56 hours per week of consumer directed personal assistance program.  The patient has been approved for 30 hours per week based on previous assessment.  

Assessment performed shows modified independence with cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing medications, and shopping; extensive assistance with managing finances, transportation, bathing, lower body dressing, locomotion, toileting, and bed mobility; limited assistance with personal hygiene, upper body dressing, and walking; and independent with eating. He is frequently incontinent of bladder and infrequently incontinent. of bowels.  This assessment compared to assessment performed earlier in the year shows decline in toilet use, walking, locomotion, and bed mobility.  He has a bedside commode, cane, shower chair, shower grab bar, walker, wheelchair, and incontinent supplies.   Appeal letter from doctor states the patient is mostly wheelchair bound.  He is easily fatigued and requires assistance with all activities of daily living (ADLs).  Due to decreasing cardiopulmonary function and worsening arthritis, 30 hours per week is insufficient to meets his needs.  He urinates frequently due to medications and needs to be attended for all transfers to minimize chance of falling due to blood thinners.  Appeal letter from the daughter states she has been providing care but she will have to return to work.  She states the patient's condition has deteriorated since first starting the program.  He is less mobile and more forgetful.  She states the patient requires total assistance with transfers and ambulation as well as activities of daily living (ADL) already accounted for in the assessment.

Yes, the proposed Increase in Consumer Directed Personal Assistance Program (CDPAP) to 8 Hours Per Day, 7 Days  A Week, A Total of 56 Hours Per Week is medically necessary.

Medically necessary services are those which are:  1) safe, 2) effective, 3) generally accepted national standard of medical practice, 4) not provided primarily for convenience of the patient or the practitioner, and 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice.

Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient was approved for 30 personal care service (PCS) hours per week based on assessments performed.  The patient lives with his daughter who provides care.  The most recent assessment shows the patient needs assistance with activities of daily living in all areas except eating.  This assessment compared to assessment performed earlier in the year shows a decline in toilet use, walking, locomotion, and bed mobility.  

Appeal letters from the doctor and daughter state that the patient's functional status has deteriorated, and the patient requires more assistance.  The letters notes the patient is wheelchair bound and requires total assistance with transfers and ambulation.  The most recent assessment performed shows there was a progression in deterioration of the patient's functional status compared to the assessment performed previously.  Appeal letters show the patient's functional status continues to deteriorate.  Based on the progression of this patient's condition, the currently approved 30 personal care service (PCS) hours per week are insufficient to meet this patient's needs for assistance with activities of daily living (ADLs) and personal care.  The proposed 56 hours are appropriate for this patient.