Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other - Limited range of motion
Treatment: Consumer Directed Personal Assistance Program (CDPAP) services for a total amount 28 hours per week 

The health plan denied: Consumer Directed Personal Assistance Program (CDPAP) services for a total amount 28 hours per week 
The determination is: Overturned

The patient is a male with medical history notable for coronary artery disease, benign prostatic hyperplasia, and hypertension. The patient is approved for 4 hours per day, 5 days per week (20 hours per week) of Consumer Directed Personal Assistance Program (CDPAP). The patient and his care team requested an increase to 4 hours per day, 7 days per week (28 hours per week).

The patient's son provided a letter of support for this appeal. The letter states that the patient was living with his wife, but recently moved into an apartment where he now lives alone due to a pending divorce filing. He was receiving informal support from his wife on the weekends but is no longer receiving it. He has difficulty with dressing, showering, food preparation, and stairs on the weekend when no formal support person is present. The patient's children are supportive of the patient but not able to provide consistent personal care support on the weekend.

A Uniform Assessment System (UAS) was completed and available for review. The assessment was conducted via teleconference. The patient lives alone in an apartment which is on the second floor. He was alert and oriented but had forgetfulness at times. His short term and procedural memory was intact. For his instrumental activities of daily living (IADL), he requires total dependence for housework. He requires maximal dependence for meal preparation, medications, and shopping. He requires extensive assistance for stairs and transportation. For his activities of daily living (ADL), he requires extensive assistance for bathing and dressing his lower body. He requires limited assistance for hygiene, dressing his upper body, walking, locomotion, and toilet transfer. He is continent of stool and urine. A task tool associated with the assessment recommended 3.5 hours per day, 5 days per week (17.5 hours per week) to address his personal care needs. Compared to a prior UAS, the patient's functional status remained similar. The task tool at that time recommended 22.5 hours per week to address his needs.

At issue is the medical necessity of CDPAP services 28 hours per week.

The health plan's determination of medical necessity is overturned in whole.

The requested health service of increase in Consumer Directed Personal Assistance Program (CDPAP) services for a total amount 28 hours per week is medically necessary for this patient.

The patient has been receiving informal support on the weekends from his wife but will no longer be receiving this moving forward. The UAS demonstrates that he requires assistance with all IADL's and several ADL's. He will need support with these tasks on the weekends as well. The task tool can provide an approximation for the hours required but cannot be the final determining factor. The case files document the patient's personal care needs which are not being met on the weekends. Therefore, the requested increase in personal care hours to provide coverage for these needs on the weekends is reasonable and medically necessary for the patient.